Correlation of the Risk Factors in Degenerative Lumbar Spondylolisthesis with MRI Imaging

@#Introduction: Degenerative spondylolisthesis burdens the future economy. Elderly individuals with this condition suffer from back pain, limb paralysis, reduced activity, and diminished quality of life. Surgery offers relief but is risky and expensive. As healthcare improves, the aging population grows, and spondylolisthesis incidence rises. Early detection and risk factor management are vital for prevention. Therefore, this study aimed to evaluate the correlation of the risk factors for degenerative lumbar spondylolisthesis. Methods: A retrospective observational study was done in Dr Soetomo General Academic Hospital, Surabaya from January 2018 to December 2019. Forty-five subjects with degenerative spondylolisthesis diagnosed by MR Imaging enrolled in this study. Intervertebral disc, facet joint, multifidus muscle, and ligamentum flavum at level L1 until level L5 were examined using MR imaging. Correlation analysis was measured using the Spearman correlation test and risk factor analysis was measured using the logistic regression test. Results: There are significant correlations between intervertebral disc degeneration, facet joint osteoarthritis, multifidus muscle fatty infiltration, and thickening of ligamentum flavum with degenerative spondylolisthesis. The risk factors at levels L3-4 and L5-S1 are intervertebral disc degeneration and L4-5 is multifidus muscle fatty infiltration and facet joint osteoarthritis. Conclusion: This study confirmed the risk factors that correlated with degenerative lumbar spondylolisthesis.

Prediction of risk factors of occurrence and development of degenerative lumbar spondylolisthesis with sagittal parameters of the spine and pelvis / 临床外科杂志

Objective To explore the risk factors related to the development and progression of lumbar degenerative spondylolisthesis (LDS).Methods A total of 71 patients with LDS or degenerative spinal stenosis (DSS) were retrospectively.Thirty-six patients with LDS (group LDS) and 35 patients with DSS (group DSS) were enrolled.Spinopelvic parameters including pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), thoracic kyphosis (TK), regional lumbopelvic lordosis angles (PR-LI, PR-L2, PR-L3, PR-L4, PR-L5), pelvic morphology (PR-S1), lumbar 4 slope (L4 S) and lumbar 5 slope (L5 S) were assessed on whole spine lateral radiographs in a standing position.All the parameters from LDS will compared with those of DSS and normal population respectively, Student's t-test was used to compare each parameter among the LDS, DSS and normal population.Results PI [ (57.67±11.78) °], SS [ (37.83±9.17) °] and LL [ (54.65±11.45) °] in group LDS were significantly greater than those of group DSS [ (44.47±8.75) °, (28.18±9.02) °, (38.97±15.59) °] and normal reference value [ (44.75±9.01) °, (33.57±7.64) °, (48.75±10.03) °] (P＜0.05).L4 S [ (8.18±9.98) °] and L5 S [ (19.96±8.33) °] in group LDS were greater than the group DSS[ (3.32±7.95) °, (10.87±8.02) °] (P＜0.05).The PR-L4 [ (57.63±13.44) °], PR-L5 [ (45.76±10.92) °] and PR-S1 [ (27.91±10.41) °] in group LDS were significantly smaller than those of group DSS [ (65.48±10.70) °, (56.33±9.15) °, (38.63±7.29) °] (P＜0.05).Conclusion Greater PI may lead to the development and progression of lumbar degenerative spondylolisthesis.L5 S is a parameter that can be used to predict the risk of LDS.The lower regional lumbopelvic lordosis angles in LDS were smaller than those of DSS.

Concurrent Degenerative Cervical and Lumbar Spondylolisthesis / 대한척추외과학회지

STUDY DESIGN: Retrospective radiographic study. OBJECTIVES: To evaluate the characteristics of concurrent degenerative cervical and lumbar spondylolisthesis. SUMMARY OF LITERATURE REVIEW: Concurrent degenerative cervical and lumbar spondylotic diseases have been reported. Given that severe spondylosis can result in spondylolisthesis, one might expect that concurrent spondylolisthesis of the cervical and lumbar spines might also be prevalent. However, the incidence of spondylolistheses in the lumbar and cervical spines might differ due to anatomical differences between the 2 areas. Nonetheless, there is minimal information in the literature concerning the incidence of concurrent cervical and lumbar spondylolisthesis. MATERIAL AND METHODS: We evaluated standing cervical and lumbar lateral radiographs of 2510 patients with spondylosis. Concurrence, age group, gender, and direction of spondylolisthesis were evaluated. Lumbar spondylolisthesis was defined as at least Meyerding grade I and degenerative cervical spondylolisthesis was defined as over 2 mm of displacement on standing lateral radiographs. RESULTS: Lumbar spondylolisthesis was found in 125 patients (5.0%) and cervical spondylolisthesis was found in 193 patients (7.7%). Seventeen patients had both degenerative cervical and lumbar spondylolistheses (0.7%). Lumbar spondylolisthesis is a risk factor for co-existing cervical spondylolisthesis. Lumbar spondylolisthesis was more common in females than males, independent of advancing age. In contrast, degenerative cervical spondylolisthesis was more common in older patients, independent of gender. Anterolisthesis was more common in the lumbar spine. Retrolisthesis was more common in the cervical spine. CONCLUSIONS: There was a higher prevalence of degenerative cervical spondylolisthesis in patients with degenerative lumbar spondylolisthesis.

Comparison of Clinical and Radiological Outcomes of Lumbar Interbody Fusion Using a Combination of Hydroxyapatite and Demineralized Bone Matrix and Autografts for Lumbar Degenerative Spondylolisthesis

STUDY DESIGN: Prospective, cohort, non-inferiority study. PURPOSE: This study evaluated the clinical and radiological outcomes of interbody fusion using a combination of demineralized bone matrix (DBM) and hydroxyapatite (HA). OVERVIEW OF LITERATURE: The use of autografts remains a gold standard in lumbar interbody fusion, but the limited availability and donor site morbidity encourages the use of bone substitutes. In addition to autografts, a combination of HA and DBM is being increasingly use for lumbar interbody fusion. However, there are no data on the clinical and radiological outcomes of this procedure. METHODS: We examined 35 patients with lumbar degenerative spondylolisthesis who underwent transforaminal interbody fusion. Autografts were used in 18 patients, and 17 patients received a combination of HA and DBM. Clinical outcomes were evaluated using the visual analog scale (VAS) for back and leg pain, Oswestry disability index (ODI), and Japanese Orthopaedic Association (JOA) scores at 3, 6, and 12 months postoperatively. Fusion was evaluated using computed tomography images obtained at 12 months postoperatively. RESULTS: The mean ODI, JOA, and back and leg pain VAS scores increased significantly in both groups. However, the VAS, JOA, and ODI scores did not differ significantly between the two groups (p=0.599, p=0.543, and p=0.780, respectively). The fusion rates at 1 year postoperatively were 77.8% and 76.5% in the autograft and HA+DBM groups, respectively (p=0.99). CONCLUSIONS: The clinical and radiological outcomes of using a combination of HA and DBM in lumbar interbody fusion were not inferior to those of using autografts. A combination of HA and DBM can be considered as an alternative in patients with lumbar degenerative spondylolisthesis requiring surgery.

Nonoperative versus operative treatment of patients with degenerative spondylolisthesis / Tratamento conservador versus cirúrgico de pacientes com espondilolistese degenerativa / Tratamiento conservador contra quirúrgico de pacientes con espondilolistesis degenerativa

ABSTRACT Objective: To evaluate clinical and functional results of patients with lumbar degenerative spondylolisthesis treated with operatively or nonoperatively. Methods: Patients with degenerative spondylolisthesis treated either nonoperatively or operatively from 2004 to 2014 were selected from databases and a cross-sectional evaluation was performed. Outcome measures included back and leg visual analogue scales (VAS), Fischgrund criteria, Short Form-36 (SF-36) function score, and the modified Oswestry Disability Index (ODI). Results: 43 patients were evaluated: 20 with nonoperative treatment and 23 with operative treatment. Baseline characteristics were similar without significant differences between groups. Mean follow-up time was 43 months (range 10 - 72) for the nonoperative group and 36 months (range 6-80) for the operative group. Significant statistical difference in favor of operative group were found in back VAS (mean 4 versus 8, p = 0.000), leg VAS (mean 3 versus 6, p = 0.0015), SF-36 function score (mean 77 versus 35, p = 0.000), and ODI (mean 17 versus 46, p = 0.000). On the basis of the Fischgrund criteria, only 10 % of patients reported excellent or good health post nonoperative treatment versus 83% for those treated operatively (p = 0.000). Conclusion: In this cross-sectional study, we observed that symptomatic patients with degenerative spondylolisthesis who underwent operative treatment have superior clinical and functional scores compared to those that underwent nonoperative treatment.

RESUMO Objetivo: Avaliar os resultados clínicos e funcionais dos pacientes com espondilolistese degenerativa lombar tratados de maneira conservadora ou cirúrgica. Métodos: Foram selecionados pacientes com espondilolistese degenerativa tratados conservadoramente ou submetidos à cirurgia, durante 2004-2014, à partir da coleta de dados que possibilitou a realização da avaliação transversal. As medidas de avaliação da dor lombar e das pernas foram escalas analógicas visuais (VAS), critérios Fischgrund, Short Form-36 (SF-36) pontuação funcional, e o Índice de Incapacidade Oswestry modificado (ODI). Resultados: 43 pacientes foram avaliados: 20 do tratamento conservador e 23 do tratamento cirúrgico. As características de base foram similares, sem diferenças significativas entre os grupos. O tempo médio de acompanhamento foi de 43 meses (intervalo 10-72) para o grupo não-cirúrgico e 36 meses (intervalo 6-80) para o grupo cirúrgico. Diferenças estatísticas significativas em favor do grupo cirúrgico foram encontrados no VAS lombar (média de 4 versus 8, p = 0,000), VAS pernas (média 3 contra 6, p = 0,0015), SF-36 pontuação funcional (média 77 versus 35, p = 0,000), e ODI (média 17 versus 46, p = 0,000). Com base nos critérios Fischgrund, apenas 10% dos pacientes relataram excelente ou boa saúde de após o tratamento conservador contra 83% para aqueles tratados no cirúrgico (p = 0,000). Conclusão: Neste estudo transversal, observou-se que os pacientes sintomáticos com espondilolistese degenerativa que se submeteram ao tratamento cirúrgico têm escores clínicos e funcionais superiores em comparação àqueles que foram submetidos a tratamento conservador.

RESUMEN Objetivo: Evaluar los resultados clínicos y funcionales de los pacientes con espondilolistesis degenerativa lumbar tratados quirúrgicamente o sin cirugía. Métodos: Se realizó una evaluación transversal de los pacientes con espondilolistesis degenerativa, registrados en la base de datos, tratados conservador o quirúrgicamente desde 2004 hasta 2014. Las medidas de desenlace incluyeron: Escala Visual Análoga (EVA) de dolor lumbar y las piernas, criterios de Fischgrund, Short Form-36 (SF-36) e Índice de Discapacidad Oswestry modificado (IDO). Resultados: Se evaluaron 43 pacientes: 20 con tratamiento no quirúrgico y 23 con tratamiento quirúrgico. Las características de base fueron similares, sin diferencias significativas entre los grupos. El tiempo medio de seguimiento fue de 43 meses (rango 10-72) para el grupo no quirúrgico y 36 meses (rango 6-80) para el grupo quirúrgico. Diferencias estadísticamente significativas a favor del grupo quirúrgico fueron encontrados en EVA lumbar (media 4 contra 8, p=0,000), EVA pierna (media 3 contra 6, p=0,0015), SF-36 función (media 77 contra 35, p=0,000), e IDO (media 17 contra 46, p=0,000). Con respecto a los criterios de Fischgrund, sólo el 10% de los pacientes del grupo que recibió tratamiento no quirúrgico informo excelente o buen estado de salud en comparación con 83% de los que recibieron manejo quirúrgico (p = 0,000) Conclusión: En este estudio de corte transversal, se observó que los pacientes sintomáticos con espondilolistesis degenerativa que se sometieron a tratamiento quirúrgico tienen puntuaciones clínicas y funcionales superiores en comparación con los que se sometieron a tratamiento no quirúrgico.

The progress of minimally invasive surgery for degenerative lumbar spondylolisthesis / 中国基层医药

In this paper,based on the latest domestic and foreign literatures,segmental stability in degenera-tive spondylolisthesis,therapeutic principles,indications and new progress of many minimally invasive surgery of this disease are described in detail.Minimally invasive surgical procedures for degenerative lumbar spondylolisthesis is diversity,so we should choose the best treatment for every patient according to the age,basic diseases,the degree of slipped levels,segmental stability of slipped vertebraes,ecnomic factors in patients,combined with operation skills of surgeons.

Associated Factors for Lumbar Degenerative Spondylolisthesis in Japanese Patients with Osteoarthritis of the Hip: A Radiographic Study

STUDY DESIGN: Retrospective study. PURPOSE: To determine the presence and frequency of factors for degenerative spondylolisthesis (DS) in patients with hip osteoarthritis (OA). OVERVIEW OF LITERATURE: OA of the hip joint (hip OA) in Japanese patients is associated with a high incidence of degenerative lumbar spondylolisthesis (DS). However the associated factors for DS in patients with hip OA are unclear. METHODS: The study included 518 patients (59 men and 459 women) with a mean age of 63.8 years who underwent total hip arthroplasty for hip OA at our hospital between January 2004 and May 2014. The presence of DS was assessed using preoperative standing lateral radiographs of the hip joint including the lower lumbar spine. To identify the associated factors for DS in patients with hip OA, multiple logistic regression analysis was conducted in which the presence or absence of DS was used as a dependent variable, and age, female sex, body mass index (BMI), sacral slope (SS), Crowe classification, and primary OA (P-OA) not associated with acetabular dysplasia were independent variables. RESULTS: Patients with DS accounted for 114 (22.0%) of 518 cases. In multiple logistic regression analysis to identify associated factors for DS in patients with hip OA, the odds ratio for age was 1.05 (95% confidence interval [CI], 1.02–1.08), female sex was 2.48 (95% CI, 1.11–5.54), BMI was 1.08 (95% CI, 1.02–1.14), SS was 1.07 (95% CI, 1.04–1.09), Crowe classification was 0.60 (95% CI, 0.40–0.91), and P-OA was 1.90 (95% CI, 1.20–3.75). CONCLUSIONS: Age, female sex, BMI, SS, low Crowe classification, and P-OA are independently associated factors for DS in patients with hip OA.

Radiological Evaluation of the Initial Fixation between Cortical Bone Trajectory and Conventional Pedicle Screw Technique for Lumbar Degenerative Spondylolisthesis

STUDY DESIGN: Retrospective study. PURPOSE: To compare initial fixation using the cortical bone trajectory (CBT) technique versus conventional pedicle screws (PS) in radiographs of postsurgical lumbar degenerative spondylolisthesis. OVERVIEW OF LITERATURE: Few reports have documented the holding strength of CBT technique for spondylolisthesis cases. METHODS: From October 2009 to June 2014, 21 cases of degenerative spondylolisthesis were surgically treated in our institution. Ten were treated with conventional PS technique and 11 of with CBT technique. Mean lumbar lordosis and percent slippage were evaluated preoperatively, immediately after surgery, and 6 months and 1 year postoperatively using radiographs. We also investigated percent loss of slip reduction. RESULTS: There were statistically significant differences between preoperative percent slippage and postoperative slippage in both PS and CBT procedures over 1 year, and both techniques showed good slip reduction. On the other hand, lumbar lordosis did not change significantly in either the PS or CBT groups over 1 year. CONCLUSIONS: CBT technique showed similarly good initial fixation compared with the PS procedure in the treatment of lumbar degenerative spondylolisthesis.

Lumbar Interspinous Process Fixation and Fusion with Stand-Alone Interlaminar Lumbar Instrumented Fusion Implant in Patients with Degenerative Spondylolisthesis Undergoing Decompression for Spinal Stenosis

STUDY DESIGN: Prospective cohort study. PURPOSE: To assess the ability of a stand-alone lumbar interspinous implant (interspinous/interlaminar lumbar instrumented fusion, ILIF) associated with bone grafting to promote posterior spine fusion in degenerative spondylolisthesis (DS) with vertebral instability. OVERVIEW OF LITERATURE: A few studies, using bilateral laminotomy (BL) or bilateral decompression by unilateral laminotomy (BDUL), found satisfactory results in stenotic patients with decompression alone, but others reported increased olisthesis, or subsequent need for fusion in DS with or without dynamic instability. METHODS: Twenty-five patients with Grade I DS, leg pain and chronic low back pain underwent BL or BDUL and ILIF implant. Olisthesis was 13% to 21%. Follow-up evaluations were performed at 4 to 12 months up to 25 to 44 months (mean, 34.4). Outcome measures were numerical rating scale (NRS) for back and leg pain, Oswestry disability index (ODI) and short-form 36 health survey (SF-36) of body pain and function. RESULTS: Fusion occurred in 21 patients (84%). None had increased olisthesis or instability postoperatively. Four types of fusion were identified. In Type I, the posterior part of the spinous processes were fused. In Type II, fusion extended to the base of the processes. In Type III, bone was present also around the polyetheretherketone plate of ILIF. In Type IV, even the facet joints were fused. The mean NRS score for back and leg pain decreased by 64% and 80%, respectively. The mean ODI score was decreased by 52%. SF-36 bodily pain and physical function mean scores increased by 53% and 58%, respectively. Computed tomography revealed failed fusion in four patients, all of whom still had vertebral instability postoperatively. CONCLUSIONS: Stand-alone ILIF with interspinous bone grafting promotes vertebral fusion in most patients with lumbar stenosis and unstable Grade I DS undergoing BL or BDUL.

Comparison of Clinical and Radiological Results of Posterolateral Fusion and Posterior Lumbar Interbody Fusion in the Treatment of L4 Degenerative Lumbar Spondylolisthesis

STUDY DESIGN: Multicenter analysis of two groups of patients surgically treated for degenerative L4 unstable spondylolisthesis. PURPOSE: To compare the clinical and radiographic outcomes of posterolateral fusion (PLF) and posterior lumbar interbody fusion (PLIF) for degenerative L4 unstable spondylolisthesis. OVERVIEW OF LITERATURE: Surgery for lumbar degenerative spondylolisthesis is widely performed. However, few reports have compared the outcome of PLF to that of PLIF for degenerative L4 unstable spondylolisthesis. METHODS: Patients with L4 unstable spondylolisthesis with Meyerding grade II or more, slip of >10degrees or >4 mm upon maximum flexion and extension bending, and posterior opening of >5 degree upon flexion bending were studied. Patients were treated from January 2008 to January 2010. Patients who underwent PLF (n=12) and PLIF (n=19) were followed-up for >2 years. Radiographic findings and clinical outcomes evaluated by the Japanese Orthopaedic Association (JOA) score were compared between the two groups. Radiographic evaluation included slip angle, translation, slip angle and translation during maximum flexion and extension bending, intervertebral disc height, lumbar lordotic angle, and fusion rate. RESULTS: JOA scores of the PLF group before surgery and at final follow-up were 12.3+/-4.8 and 24.1+/-3.7, respectively; those of the PLIF group were 14.7+/-4.8 and 24.2+/-7.8, respectively, with no significant difference between the two groups. Correction of slip estimated from postoperative slip angle, translation, and maintenance of intervertebral disc height in the PLIF group was significantly (p<0.05) better than those in the PLF group. However, there was no significant difference in lumbar lordotic angle, slip angle and translation angle upon maximum flexion, or extension bending. Fusion rates of the PLIF and PLF groups had no significant difference. CONCLUSIONS: The L4-L5 level posterior instrumented fusion for unstable spondylolisthesis using both PLF and PLIF could ameliorate clinical symptoms when local stability is achieved.

A Comparative Study of Lateral Lumbar Interbody Fusion and Posterior Lumbar Interbody Fusion in Degenerative Lumbar Spondylolisthesis

STUDY DESIGN: Level 4 retrospective review. PURPOSE: To compare the radiographic and clinical outcomes between posterior lumbar interbody fusion (PLIF) and lateral lumbar interbody fusion (LLIF) with posterior segmental spinal instrumentation (SSI) for degenerative lumbar spondylolisthesis. OVERVIEW OF LITERATURE: Both PLIF and LLIF have been performed for degenerative spondylolisthesis with good results, but no study has directly compared these two techniques so far. METHODS: The electronic medical and radiographic records of 78 matched patients were analyzed. In one group, 39 patients underwent PLIF with SSI at 41 levels (L3-4/L4-5), while in the other group, 39 patients underwent the LLIF procedure at 48 levels (L3-4/L4-5). Radiological outcomes such as restoration of disc height and neuroforaminal height, segmental lumbar lordosis, total lumbar lordosis, incidence of endplate fracture, and subsidence were measured. Perioperative parameters were also recorded in each group. Clinical outcome in both groups was assessed by the short form-12, Oswestry disability index and visual analogue scale scores. The average follow-up period was 16.1 months in the LLIF group and 21 months in the PLIF group. RESULTS: The restoration of disc height, foraminal height, and segmental lumbar lordosis was significantly better in the LLIF group (p<0.001). The duration of the operation was similar in both groups, but the average blood loss was significantly lower in the LLIF group (p<0.001). However, clinical outcome scores were similar in both groups. CONCLUSIONS: Safe, effective interbody fusion can be achieved at multiple levels with neuromonitoring by the lateral approach. LLIF is a viable treatment option in patients with new onset symptoms due to degenerative spondylolisthesis who have had previous lumbar spine surgery, and it results in improved sagittal alignment and indirect foraminal decompression.

Semi-Circumferential Decompression: Microsurgical Total en-bloc Ligamentum Flavectomy to Treat Lumbar Spinal Stenosis with Grade I Degenerative Spondylolisthesis

BACKGROUND: To describe and assess clinical outcomes of the semi-circumferential decompression technique for microsurgical en-bloc total ligamentum flavectomy with preservation of the facet joint to treat the patients who have a lumbar spinal stenosis with degenerative spondylolisthesis. METHODS: We retrospectively analyzed the clinical and radiologic outcomes of 19 patients who have a spinal stenosis with Meyerding grade I degenerative spondylolisthesis. They were treated using the "semi-circumferential decompression" method. We evaluated improvements in back and radiating pain using a visual analogue scale (VAS) and the Oswestry Disability Index (ODI). We also evaluated occurrence of spinal instability on radiological exam using percentage slip and slip angle. RESULTS: The mean VAS score for back pain decreased significantly from 6.3 to 4.3, although some patients had residual back pain. The mean VAS for radiating pain decreased significantly from 8.3 to 2.5. The ODI score improved significantly from 25.3 preoperatively to 10.8 postoperatively. No significant change in percentage slip was observed (10% preoperatively vs. 12.2% at the last follow-up). The dynamic percentage slip (gap in percentage slip between flexion and extension X-ray exams) did not change significantly (5.2% vs. 5.8%). Slip angle and dynamic slip angle did not change (3.2° and 8.2° vs. 3.6° and 9.2°, respectively). CONCLUSIONS: The results suggested that semi-circumferential decompression is a clinically recommendable procedure that can improve pain. This procedure does not cause spinal instability when treating patients who have a spinal stenosis with degenerative spondylolisthesis.

Comparison of Functional Outcomes following Surgical Decompression and Posterolateral Instrumented Fusion in Single Level Low Grade Lumbar Degenerative versus Isthmic Spondylolisthesis

BACKGROUND: The two most common types of surgically treated lumbar spondylolisthesis in adults include the degenerative and isthmic types. The aim of this study was to compare the functional outcomes of surgical decompression and posterolateral instrumented fusion in patients with lumbar degenerative and isthmic spondylolisthesis. METHODS: In this retrospective study, we reviewed the clinical outcomes in surgically treated patients with single level, low grade lumbar degenerative, and isthmic spondylolisthesis (groups A and B, respectively) from August 2007 to April 2011. We tried to compare paired settings with similar initial conditions. Group A included 52 patients with a mean age of 49.2 +/- 6.1 years, and group B included 52 patients with a mean age of 47.3 +/- 7.4 years. Minimum follow-up was 24 months. The surgical procedure comprised neural decompression and posterolateral instrumented fusion. Pain and disability were assessed by a visual analog scale (VAS) and the Oswestry Disability Index (ODI), respectively. The Wilcoxon and Mann-Whitney U-tests were used to compare indices. RESULTS: The most common sites for degenerative and isthmic spondylolisthesis were at the L4-L5 (88.5%) and L5-S1 (84.6%) levels, respectively. Surgery in both groups significantly improved VAS and ODI scores. The efficacy of surgery based on subjective satisfaction rate and pain and disability improvement was similar in the degenerative and isthmic groups. Notable complications were also comparable in both groups. CONCLUSIONS: Neural decompression and posterolateral instrumented fusion significantly improved pain and disability in patients with degenerative and isthmic spondylolisthesis. The efficacy of surgery for overall subjective satisfaction rate and pain and disability improvement was similar in both groups.

A comparison of Decompression and Fusion Surgery in Lumbar Degenerative Spondylolisthesis

STUDY DESIGN: A retrospective, controlled study. OBJECTIVES: To assess clinical and radiologic results of decompression without fusion surgery in the treatment of stable lumbar degenerative spondylolisthesis (LDS) and to compare clinical outcomes of fusion surgery. SUMMARY OF LITERATURE REVIEW: Although it is reported that decompression surgery is effective in treating LDS, few reports have compared the outcomes of treatment using decompression and instrumented fusion. MATERIALS AND METHODS: A retrospective study was performed and fifty eight degenerative spondylolisthesis patients who received decompression treatment with or without fusion surgery with follow up for at least 2 years were included. The number of patients in the decompression and fusion groups were 23 each and they were selected with age and slip degree taken into account. Clinical factors were evaluated using the Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) of the back/leg and high risk of operation. Radiological factors were evaluated such as slippage, angulation, and disc height at the affected level in preoperative and final follow up. RESULTS: There was no statistical difference between the decompression and fusion groups in the VAS of the back/leg, slippage, and high risk of operation preoperatively (p>0.05). The mean operative time was 73.9 minutes in the decompression group and 123.7 minutes in the fusion group. The mean blood loss was 134.5mL in the decompression group and 323.5mL in the fusion group. VAS of the back/leg and ODI improved in both groups and there were no significant differences between the two groups statistically. CONCLUSIONS: Decompression with/without fusion had a favorable clinical outcome in stable degenerative spondylolisthesis patients. However, fusion involves more operative time and blood loss compared to simple decompression. Simple decompression is a good treatment option, especially in operative high risk patients.

Comparison of Sagittal Spinopelvic Alignment between Lumbar Degenerative Spondylolisthesis and Degenerative Spinal Stenosis

OBJECTIVE: The purpose of this study was to evaluate the differences in sagittal spinopelvic alignment between lumbar degenerative spondylolisthesis (DSPL) and degenerative spinal stenosis (DSS). METHODS: Seventy patients with DSPL and 72 patients with DSS who were treated with lumbar interbody fusion surgery were included in this study. The following spinopelvic parameters were measured on whole spine lateral radiographs in a standing position : pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis angle (LL), L4-S1 segmental lumbar angle (SLL), thoracic kyphosis (TK), and sagittal vertical axis from the C7 plumb line (SVA). Two groups were subdivided by SVA value, respectively. Normal SVA subgroup and positive SVA subgroup were divided as SVA value ( or =50 mm). Spinopelvic parameters/PI ratios were assessed and compared between the groups. RESULTS: The PI of DSPL was significantly greater than that of DSS (p=0.000). The SVA of DSPL was significantly greater than that of DSS (p=0.001). In sub-group analysis between the positive (34.3%) and normal SVA (65.7%), there were significant differences in LL/PI and SLL/PI (p<0.05) in the DSPL group. In sub-group analysis between the positive (12.5%) and normal SVA (87.5%), there were significant differences in PT/PI, SS/PI, LL/PI and SLL/PI ratios (p<0.05) in the DSS group. CONCLUSION: Patients with lumbar degenerative spondylolisthesis have the propensity for sagittal imbalance and higher pelvic incidence compared with those with degenerative spinal stenosis. Sagittal imbalance in patients with DSPL is significantly correlated with the loss of lumbar lordosis, especially loss of segmental lumbar lordosis.

Difference of Sagittal Spinopelvic Alignments between Degenerative Spondylolisthesis and Isthmic Spondylolisthesis

OBJECTIVE: The purpose of this study was to analyze the differences of spinopelvic parameters between degenerative spondylolisthesis (DSPL) and isthmic spondylolisthesis (ISPL) patients. METHODS: Thirty-four patients with DSPL and 19 patients with ISPL were included in this study. Spinopelvic parameters were evaluated on whole spine X-rays in a standing position. The following spinopelvic parameters were measured : pelvic incidence (PI), sacral slope, pelvic tilt (PT), lumbar lordosis (LL), and sagittal vertical axis from C7 plumb line (SVA). The population of patients was compared with a control population of 30 normal and asymptomatic adults. RESULTS: There were statistically significant differences in LL (p=0.004) and SVA (p=0.005) between the DSPL and ISPL group. The LL of DSPL (42+/-13degrees) was significantly lower than that of the control group (48+/-11degrees; p=0.029), but that of ISPL (55+/-6degrees) was significantly greater than a control group (p=0.004). The SVA of DSPL (55+/-49 mm) was greater than that of a control group (<40 mm), but that of ISPL (21+/-22 mm) was within 40 mm as that of a control group. The PT of DSPL (24+/-7degrees) and ISPL (21+/-7degrees) was significantly greater than that of a control group (11+/-6degrees; p=0.000). CONCLUSION: Both symptomatic DSPL and ISPL patients had a greater PI than that of the asymptomatic control group. In conclusion, DSPL populations are likely to have global sagittal imbalance (high SVA) compared with ISPL populations because of the difference of lumbar lordosis between two groups.

The Prognostic Factor of Posterolateral Fusion in Degenerative Spondylolisthesis

STUDY DESIGN: A retrospective analysis of the posterolateral fusion in degenerative spondylolisthesis. OBJECTIVES: Posterolateral fusion has been performed for patients about Meyerding grade1, 2 with degenerative spondylolisthesis in L4-5. We evaluated the prognostic factors of posterolateral fusion, alone for degenerative spondylolisthesis. SUMMARY OF LITERATURE REVIEW: It is reported that posterolateral fusion has almost equal postoperative clinical and radiographic results with the interbody or circumferential fusion for spondylolisthesis. However, there have been some unsatisfactory results after posterolateral fusion alone and the causes are yet unknown. MATERIAL AND METHODS: From January 2002 to July 2008, we analyzed postoperative clinical outcomes of 42 patients who were diagnosed with Meyerding 1 or 2 grade degenerative spondylolisthesis at L4-5. All the patients were classified into group I and group II, based on the clinical outcome evaluation method by Kirkaldy-Willis. Ten patients (Group I) were found to have poor or fair clinical outcomes, while 32 patients (Group II) were found to have excellent or good clinical outcomes. The mean duration of the follow up was 16.3 (12-23) months. We looked into postoperative body mass index and bone mass density, and found degenrative lumbar disc through preoperative MRI, retrospectively. We measured angular motion by dynamic radiographs and preoperative slip angle through a Taillard method. RESULTS: In group I, the average preoperative BMI was 25.7 (21.2~31.4) and the average T score of bone density was -3.0 (-1.9~-4.2). There was 1 case of Grade 3, 3 cases of Grade 4 and 6 cases of Grade 5 by preoperative Pfirmann classification. The average angular motion was 11.8 (9.1~14.2) and the average preoperative slip angle was 8.4 (6.9-9.6). In group II, the average preoperative BMI was 24.3 (20.72~28.1) and the average T score of bone density was -2.1 (-0.9~-3.1). There were 26 cases of Grade 3, 5 cases of Grade 4 and 1 case of Grade 5 by preoperative Pfirmann classification. The average angular motion was 8.8 (6.2~12.1) and the average preoperative slip angle was 6.2 (3.6-7.9). There were statistically significant differences between the two groups in BMI, stage of disc degeneration, preoperative angular motion, and slip angle. (p=0.04, 0.04, 0.05, 0.03, respectively) CONCLUSION: We concluded that posterolateral fusion has exhibited worse clinical results in cases of BMI less than -2.8, disc degeneration greater than grade 4, angular motion greater than 9.4 degrees, and slip angle greater than 7.1 degrees; as such, we need to consider other surgical methods.

Association of Estrogen Receptor Gene Polymorphism in Patients with Degenerative Lumbar Spondylolisthesise

OBJECTIVE: The purpose of this study was to investigate the possible association of estrogen receptor alpha (ERalpha) gene polymorphisms in a cohort of degenerative spondylolisthesis (DS) patients. METHODS: Accordingly, the authors examined the association between DS and ERalpha gene polymorphisms in 174 patients diagnosed with DS. The Pvu II and Xba I polymorphisms, bone mineral density at the lumbar spine and femoral neck, and biochemical markers were analyzed and compared in the 174 patients with DS and 214 patients with spinal stenosis (SS). RESULTS: A comparison of genotype frequencies in DS and SS patients revealed a significant difference for the Pvu II polymorphism only (p=0.0452). No significant difference was found between these two groups with respect to the Xba I polymorphism, BMD or biochemical markers. No significant association was found between the Pvu II polymorphism of ERalpha and BMD, vertebral slip or biochemical markers in patients with DS. CONCLUSION: These results suggest that the ERalpha gene polymorphism using Pvu II restriction enzyme influences the prevalence of DS.

The BioFlex System as a Dynamic Stabilization Device: Does It Preserve Lumbar Motion?

OBJECTIVE: This study examines whether functional motion is present at one or more years after Bioflex System placement. BioFlex System is a flexible rod system which has been used to preserve motion at the area of implantation. There has not been a scientific study showing how much motion is preserved after implantation. METHODS: A total of 12 consecutive patients underwent posterior dynamic stabilization using the BioFlex System. Six patients were treated using a L3-4-5 construct and other six patients using a L4-5-S1 construct. Follow-up ranged from 12 to 33 months and standing neutral lateral, extension, flexion and posteroanterior (PA) radiographs were obtained at 3, 6, 9, and 12 months and at more than 12 months postoperatively. Range of motion (ROM), whole lumbar lordosis, and ROMs of motion segments from L2 to S1 were determined. RESULTS: Patients with a L3-4-5 construct demonstrated a decrease in mean ROM for whole lumbar decreased from 40.08 to 30.77. Mean ROM for L3-4 (6.12 to 2.20) and L4-5 (6.55 to 1.67) also decreased after one year. Patients with a L4-5-S1 construct demonstrated L4-5 (8.75 to 2.70) and L5-S1 (9.97 to 3.25) decrease of mean ROM at one year postoperatively. Lumbar lordosis was preserved at both L3-4-5 and L4-5-S1 constructs. Clinical results showed significant improvements in both study groups. CONCLUSION: The present study provides preliminary information regarding the BioFlex motion preservation system. We conclude that the BioFlex System preserves functional motion to some degree at instrumented levels. However, although total lumbar lordosis was preserved, ROMs at implantation segments were lower than preoperative values.

Sacralization of L5 in Radiological Studies of Degenerative Spondylolisthesis at L4-L5

STUDY DESIGN: Radiological analysis. PURPOSE: To investigate sacralization of L5 on radiological studies of degenerative spondylolisthesis at L4-L5. OVERVIEW OF LITERATURE: Degenerative spondylolisthesis commonly develops at L4-L5. Sacralization of L5 is thought to cause stress concentration at this level, which accentuates degenerative changes and promotes development of degenerative spondylolisthesis. However, there has been no study dedicated to determining whether the presence of sacralization at L5 influences the radiological findings in degenerative spondylolisthesis at L4-L5. METHODS: Seventy-eight patients with degenerative spondylolisthesis at L4-L5 were classified into two groups according to the presence of L5 sacralization: with (n=54) and without (n=24). Four radiographic parameters were measured and compared between the two groups: anterior slippage of L4 on L5 (% slip), facet orientation of L4-L5 (degrees), facet osteoarthritis of L4-L5 by Fujiwara's criteria (1~4 grades), and disc degeneration of L4-L5 by Frymoyer's criteria (grades 1~5). RESULTS: There was no significant difference in the degree of anterior slippage of L4 on L5 (17.02+/-6.21 versus 16.65+/-4.87, p=0.809), facet orientation (54.99+/-12.18 versus 56.23+/-4.35, p=0.642), facet osteoarthritis (3.43+/-0.59 versus 3.53+/-0.37, p=0.527), or disc degeneration (4.50+/-0.51 versus 4.35+/-0.61, p=0.340) between the two groups. CONCLUSIONS: Our study shows that the influence of sacralization of L5 on radiological findings in degenerative spondylolisthesis at L4-L5 may be less significant than previously expected. Further studies in large patient groups are needed to clarify the role of L5 sacralization on the development of degenerative spondylolisthesis at L4-L5.