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.

Long term outcome of posterior lumbar pedicle screw fixation combined with isthmic bone graft fusion in the treatment of lumbar spondylolysis in young patients / 中国骨伤

OBJECTIVE@#To investigate the long-term effect of posterior lumbar pedicle screw fixation combined with isthmus bone grafting and fusion in young patients with spondylolysis.@*METHODS@#A retrospective study was carried out, consisting of 16 young patients with lumbar spondylolysis without spondylolisthesis treated by lumbar posterior pedicle screw fixation combined with isthmic bone grafting fusion from January 2006 to July 2014. There were 11 males and 5 females, aged from 18 to 21 years old, with an average age of 19.3 years old, and the course of disease ranged from 12 to 26 months, with an average of 22 months. All the patients suffered from lumbar pain and difficulty in getting out of bed. Preoperative CT confirmed 12 cases of L₅ isthmus fissure and 4 cases of L₄ isthmus fissure. Bone graft fusion was confirmed and internal fixation was removed after operation. Lumbar spondylolysis was evaluated by lumbago visual analogue scoring method at preoperative and postoperative time points. Lumbar isthmic fusion was evaluated by lumbar CT, and degeneration of fixed and adjacent segments of lumbar intervertebral disc was evaluated by lumbar MRI.@*RESULTS@#Of the 16 patients, 13 patients (26 sides) were followed up, with a mean duration of 96 months. The operation time ranged from 80 to 105 minutes, with an average of 95 minutes. The intraoperative bleeding volume ranged from 150 to 300 ml, with an average of 225 ml. All the patients were successfully operated without any complications related to the operation. VAS scores at each time point after operation were improved compared with those before operation(<0.01). Postoperative CT scans of lumbar spine showed osseous fusion at 6 to 14 months, with an average of 12 months. There were no changes of adjacent segment degeneration, fixed segment disc degeneration and protrusion on lumbar spine MRI, and no symptomatic recurrence or recurrent spondylolysis in the long term.@*CONCLUSIONS@#The posterior lumbar pedicle screw fixation combined with isthmic bone grafting and fusion is safe and effective in the treatment of young spondylolysis. The fusion rate is high and the interference of normal physiological range is reduced. The long-term effect is satisfactory.

The Evidence for Nonoperative Treatment of Lumbar Spinal Diseases / 대한척추외과학회지

STUDY DESIGN: Review article.OBJECTIVES: To assess the evidence for nonoperative treatment of various degenerative spinal degenerative diseases.SUMMARY OF LITERATURE REVIEW: No study has yet evaluated the evidence for preoperative nonoperative treatment of lumbar spinal diseases.METHODS: The evidence regarding nonoperative treatment for each disease was reviewed through NASS guidelines, and the treatment effect compared to surgical treatment was reviewed through the SPORT series. The efficacy of nonoperative treatment according to disease severity and certain special conditions was investigated through corresponding individual articles.RESULTS: No kind of nonoperative treatment could change the fundamental progression of degenerative spinal disease. The natural course of lumbar disc herniation is favorable regardless of treatment. More than 70% of routine cases improve within 6 weeks. However, it does not take a full 6 weeks to decide whether to perform surgery or not. The evidence for transforaminal epidural steroid injections for short-term pain control is grade A. There is grade B evidence for nonoperative treatment with the goal of mid- to long-term pain control. However, we cannot say that those outcomes are better than the natural course of the disease itself. In cases of radicular weakness, the degree of weakness is correlated with the final outcomes, but it is not evident whether the duration of weakness is correlated with surgical outcomes. Early surgery is usually necessary due to intolerable pain, rather than stable motor weakness. The social cost of herniated discs arises from the loss of patients’ productivity, rather than from direct medical expenses. The natural course of spinal stenosis involves provoked pain and the need for palliative care. Unlike disc herniation, rapid deterioration and marked improvement do not occur. The symptoms of mild to moderate lumbar stenosis are unchanged in 70% of cases, improve in 15%, and worsen in 15%. No study has compared nonoperative treatment with the natural course of the disease. There is no evidence for nonoperative treatment of severe stenosis. Epidural spinal injections are effective for controlling short-term pain. Spontaneous recovery of radicular weakness does not occur, and urgent surgery is necessary in such cases. There is no evidence regarding the natural course and nonoperative treatment of degenerative spondylolisthesis. The working group consensus recommends that it should follow the pattern of nonoperative treatment of spinal stenosis when radicular stenosis symptoms are predominant. Overall, 40%–66% of cases of adult bilateral isthmic spondylolysis progress to symptomatic spondylolisthesis. No studies have investigated nonoperative treatment except physical exercise.CONCLUSIONS: Although short-term symptom amelioration can be achieved by nonoperative treatment, the fundamental progression of the disease is not affected. For conditions excluded from most studies, such as prior spine surgery, cauda equina syndrome, progressive neurological deficit, and uncontrollable severe pain associated with instability, deformity, or vertebral fractures, there were not enough studies to reach informed conclusions. Our review found no evidence regarding nonoperative treatment for such conditions. Furthermore, the treatment methods for each disease are not clearly distinguished from each other, and the techniques used for disc herniation have been applied to other diseases without any evidence.

Analysis of Forensic Identification on 32 Cases of Lumbar Spondylolysis / 法医学杂志

OBJECTIVES@#To explore the casual relationship and the significance of identification among the injury, disease and damage consequence in the disability evaluation of lumbar spondylolysis by the standard for identifying grading of disability caused by work-related injuries.@*METHODS@#The general data, injury manner, clinical treatment and the imaging examination of 32 lumbar spondylolysis cases were collected and retrospectively analyzed. According to the degree of participation in the injury and damage consequence, the identification and assessment of casual relationship was made, and the grading of disability was assessed.@*RESULTS@#For 32 cases, injury had no effect on damage consequence in 7 cases, slight effect in 5 cases, secondary effect in 13 cases, equivalent effect in 4 cases, and complete effect in 3 cases. According to the related items in the standard for identifying grading of disability caused by work-related injuries, 3 cases were rated level 7, 5 cases were level 8, 6 cases were level 9, 11 cases were level 11 among the cases which existed causal relationship.@*CONCLUSIONS@#The formation of lumbar spondylolysis is connected to the factors of age, anatomy, occupation and injury manner etc. The degree of disability should be accessed comprehensively after the analysis of the casual relationship among the injury, disease and damage consequence.

Sequential Proximal Adjacent Spondylolysis by Pars Interarticularis Fracture in Elite Soccer Player / 대한스포츠의학회지

Pars interarticularis fracture is a common finding in young soccer players with low back pain. Spondylolysis in young adults involves a defect of the pars interarticularis, occurring as a result of repeated hyperextension and rotation. Here, we describe the case of a 26-year-old male elite soccer player who was diagnosed with L3 spondylolysis 2 years previously. He visited Incheon Himchan Hospital again because of low back pain. Radiographs showed consecutive spondylolysis at the L3 and L4 levels. Physicians should be aware that repeated performance of athletic movements, such as those during soccer, might lead to consecutive levels of spondylolysis.

Facture of the Pars Interarticularis with or without Spondylolisthesis in an Adult Population in a Developing Country: Evaluation by Multidetector Computed Tomography

STUDY DESIGN: Descriptive cross-sectional study. PURPOSE: To determine the prevalence of lumbar spondylolysis and spondylolisthesis in a general adult population unrelated to lower back pain as evaluated by multidetector computed tomography. OVERVIEW OF LITERATURE: There is a significant paucity of information related to the prevalence of spondylolysis and spondylolisthesis and its degenerative changes in a general adult population unrelated to lower back pain in developing countries. METHODS: A retrospective study was conducted on abdominopelvic computed tomography (CT) scans performed between January 1st 2015 and December 31st 2015 for various clinical indications. Patients with lower back pain, with a history of trauma or road traffic accident, or referred from orthopedic or neurosurgery departments were excluded to avoid any bias. CT scans were reviewed in axial, sagittal, and coronal planes using bone window settings for evaluating spondylolysis and spondylolisthesis. RESULTS: Of 4,348 patients recruited, spondylolysis and spondylolisthesis were identified in 266 (6.1%) and 142 (3.3%) patients, respectively. Age was significantly higher in both spondylolysis and spondylolisthesis patients than in those without spondylolysis and spondylolisthesis (47.19±15.45 vs. 42.5±15.96, p60 years old, both spondylolysis (p=0.018) and spondylolisthesis (p=0.025) were significantly more prevalent in females. CONCLUSIONS: The prevalence of pars interarticularis fracture observed higher with gradual increase in the prevalence with advancing age. In particular, preponderance was significantly higher among older females.

Minimally-Invasive versus Conventional Repair of Spondylolysis in Athletes: A Review of Outcomes and Return to Play

Spondylolysis from pars fracture is a common injury among young athletes, which can limit activity and cause chronic back pain. While current literature has examined the relative benefits of surgical and conservative management of these injuries, no study has yet compared outcomes between conventional direct repair of pars defects and modern minimally invasive procedures. The goals of surgery are pain resolution, return to play at previous levels of activity, and a shorter course of recovery. In this review, the authors have attempted to quantify any differences in outcome between patients treated with conventional or minimally invasive techniques. A literature search was performed of the PubMed database for relevant articles, excluding articles describing conservative management, traumatic injury, or high-grade spondylolisthesis. Articles included for review involved young athletes treated for symptomatic spondylolysis with either conventional or minimally invasive surgery. Two independent reviewers conducted the literature search and judged articles for inclusion. All studies were classified according to the North American Spine Society standards. Of the 116 results of our initial search, 16 articles were included with a total of 150 patients. Due to a paucity of operative details in older studies and inconsistencies in both clinical methods and reporting among most articles, little quantitative analysis was possible. However, patients in the minimally invasive group did have significantly higher rates of pain resolution (p<0.001). Short recovery times were also noted in this group. Both groups experienced low complication rates, and the majority of patients returned to previous levels of activity. Surgical repair of spondylolysis in young athletes is a safe and practical therapy. Current literature suggests that while conventional repair remains effective, minimally invasive procedures better clinical outcomes. We await further data to conduct a more thorough quantitative analysis of these techniques.

Clinical Usefulness of X-Ray Findings for Non-specific Low Back Pain in Korean Farmers: FARM Study

OBJECTIVE: To elucidate the association between non-specific low back pain (NSLBP) and spinal X-ray findings in Korean farmers: Farmers' Cohort for Agricultural Work-Related Musculoskeletal disorders (FARM) study. METHODS: A total of 835 farmers (391 males, 444 females; mean age, 56.6±7.4 years) without red-flag signs of specific LBP were recruited. Presence of LBP more than one week or once a month with more than moderate degree of pain severity during the last year was assessed with a binary questionnaire (yes or no). Spinal degenerative changes were classified into disc height change (DHC) of L4-5 and L5-S1 (grade 0–5) and osteophyte formation of L5 (grade 0–5) by a radiologist based on X-ray findings. Additionally, spondylolisthesis, scoliosis and spondylolysis were assessed. RESULTS: General prevalence of NSLBP was 40.7%, revealing a higher incidence of NSLBP in female and younger farmers compared to male and older farmers (χ²=23.3, p<0.001; χ²=4.54, p<05, respectively). Among X-ray findings, DHC (L5–S1) grade 4 revealed significantly higher relative risk of NSLBP compared to grade 0 (odds ratio, 5.00; 95% confidence interval, 2.05–12.20) after adjusting age and sex, while other X-ray findings were not associated with NSLBP. CONCLUSION: The NSLBP of Korean farmers was significantly related to lumbar disc degenerative changes, suggesting clinical usefulness of X-ray findings in assessing LBP in farmers.

Reabilitação baseada em movimento para melhora de dor e atividade em indivíduos com espondilólise ou espondilolistese: revisão sistemática / Movement-based rehabilitation to reduce pain and improve activity in people with spondylolysis and spondylolisthesis: a systematic review

Introdução: Alterações em estrutura e função decorrentes de espondilólise/espondilolistese podem incluir dor lombar e/ou irradiada para membros inferiores com limitações de atividade. Objetivo: avaliar a eficácia de programas de reabilitação baseados em movimento para redução da dor e melhora de atividade em indivíduos com diagnóstico de espondilólise/espondilolistese. Método: Revisão sistemática de ensaios clínicos aleatorizados, cuja intervenção foi programa de reabilitação baseado em exercício. As medidas de desfecho foram dor e atividade. Resultados: Cinco estudos foram incluídos. Dois estudos investigaram a eficácia da intervenção experimental comparada a placebo/não-intervenção, encontrando resultados inconclusivos. Três estudos investigaram a eficácia da intervenção experimental em comparação ao tratamento cirúrgico, reportando superioridade do tratamento cirúrgico. Conclusão: Os resultados são inconclusivos em relação à eficácia da reabilitação baseada em movimento, e sugerem que é menos eficaz do que tratamentos cirúrgicos na redução da intensidade de dor e melhora de atividade de indivíduos com diagnóstico de espondilólise/espondilolistese.

Introduction: Body structure and function impairments due to spondylolysis/spondylolisthesis may include low back pain and/or radiating pain, leading to activity limitations. Objective: To investigate the efficacy of movement-based rehabilitation programs to reduce pain and improve activity in people with spondylolysis/spondylolisthesis. Method: Systematic review of randomised clinical trials. Experimental intervention was movement-based rehabilitation program and outcome measures were pain and activity. Result: Five trials were included. Two trials examined the efficacy of the experimental intervention compared with placebo/no-intervention, and found inconclusive results. Three trials examined the efficacy of the experimental intervention compared with a surgical treatment, and reported superiority in favour of the surgical treatments. Conclusion: The results are inconclusive regarding the efficacy of movement-based rehabilitation, and suggested that it is less effective than surgical treatments.

Analysis of the Injury-disease Relationship between Spondylolysis and Trauma in 26 Forensic Identifications / 法医学杂志

OBJECTIVES@#To expound the injury-disease relationship between spondylolysis and trauma for the points of forensic identification.@*METHODS@#Total 26 cases of spondylolysis were collected and the characteristics of this disease such as age, accompanied symptoms, treatment and injury manner were discussed.@*RESULTS@#The causal relationship existed between trauma and injury consequence in 2 appraised individuals and both of them aged less than 50 years old. The injury manners of both were high-energy injury with combined injury and these 2 patients were treated by operation.@*CONCLUSIONS@#The analysis of injury-disease relationship between spondylolysis and trauma should be paid attention in the middle-young age under 50 years old. More importantly, the injury-disease relationship should be analyzed in the patients who chose operative treatment.

Differences of Sagittal Lumbosacral Parameters between Patients with Lumbar Spondylolysis and Normal Adults / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Recent studies have suggested an association between elevated pelvic incidence (PI) and the development of lumbar spondylolysis. However, there is still lack of investigation for Han Chinese people concerning the normal range of spinopelvic parameters and relationship between abnormal sagittal parameters and lumbar diseases. The objective of the study was to investigate sagittal lumbosacral parameters of adult lumbar spondylolysis patients in Han Chinese population.</p><p><b>METHODS</b>A total of 52 adult patients with symptomatic lumbar spondylolysis treated in the General Hospital of Armed Police Force (Beijing, China) were identified as the spondylolysis group. All the 52 patients were divided into two subgroups, Subgroup A: 36 patients with simple lumbar spondylolysis, and Subgroup B: 16 patients with lumbar spondylolysis accompanying with mild lumbar spondylolisthesis (slip percentage <30%). Altogether 207 healthy adults were chosen as the control group. All patients and the control group took lumbosacral lateral radiographs. Seven sagittal lumbosacral parameters, including PI, pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), L5 incidence, L5 slope, and sacral table angle (STA), were measured in the lateral radiographs. All the parameters aforementioned were compared between the two subgroups and between the spondylolysis group and the control group with independent-sample t- test.</p><p><b>RESULTS</b>There were no statistically significant differences of all seven sagittal lumbosacral parameters between Subgroup A and Subgroup B. PI, PT, SS, and LL were higher (P < 0.05) in the spondylolysis group than those in the control group, but STA was lower (P < 0.001) in the spondylolysis group.</p><p><b>CONCLUSIONS</b>Current study results suggest that increased PI and decreased STA may play important roles in the pathology of lumbar spondylolysis in Han Chinese population.</p>

Sagittal Pelvic Radius in Low-Grade Isthmic Lumbar Spondylolisthesis of Chinese Population

OBJECTIVE: To investigate the variation of pelvic radius and related parameters in low-grade isthmic lumbar spondylolisthesis. METHODS: Seventy-four patients with isthmic lumbar spondylolisthesis and 47 controls were included in this study. There were 17 males and 57 females between 30 and 66 years of age, including 30 with grade I slippages and 44 grade II slippages; diseased levels included 34 cases on L4 and 40 cases on L5. Thoracic kyphosis (TK), the pelvic radius (PR), the pelvic angle (PA), pelvic morphology (PR-S1), and total lumbopelvic lordosis (PR-T12) were assessed from radiographs. RESULTS: Statistically significant differences were found for the PA, PR-T12, and PR-S1 (24.5±6.6°, 83.7±9.8°, and 25.4±11.2°, respectively) of the patients with spondylolisthesis and the healthy volunteers (13.7±7.8°, 92.9±9.2°, and 40.7±8.9°, respectively). The TK/PR-T12 ratios were between 0.15 and 0.75. However, there were no differences in all the parameters between the L4 and L5 spondylolysis subgroups (p>0.05). The TK and PR-S1 of grade II were less than grade I, but the PA was greater. The PR-T12 of female patients were less than male patients, but the PA was greater (p<0.05). CONCLUSION: Pelvic morphology differed in patients with low-grade isthmic lumbar spondylolisthesis compared to controls. Gender and the grade of slippage impacted the sagittal configuration of the pelvis, but the segment of the vertebral slip did not. Overall, the spine of those with spondylolisthesis remains able to maintain sagittal balance despite abnormal pelvic morphology.

The Variation in the Lumbar Facet Joint Orientation in an Adult Asian Population and Its Relationship with the Cross-Sectional Area of the Multifidus and Erector Spinae

STUDY DESIGN: Cross-sectional study of healthy volunteers. PURPOSE: We aimed to investigate the variation in the lumbar facet joint orientation in an adult Asian population. The relationship between the facet joint orientation and muscle cross-sectional area (CSA) of multifidus and erector spinae was also clarified. OVERVIEW OF LITERATURE: Several studies have reported that lumbar pathologies, such as lumbar spondylolysis and degenerative spondylolisthesis, were related to the horizontally shaped lumbar facet joint orientation at the lower lumbar level. However, data regarding variations in the facet joint orientation in asymptomatic subjects have not been well documented. METHODS: In 31 healthy male adult Asian volunteers, the facet joint orientation and CSA of multifidus and erector spinae were measured using magnetic resonance imaging at the L4–5 and L5–S1 levels. Variation in the facet joint orientation was examined using coefficients of variation (CV). Pearson's product-moment coefficient was used to investigate the relationship between the facet joint orientation and CSA of multifidus and erector spinae. RESULTS: Lumbar facet joint orientation had a wider range of variation at L5–S1 (CV=0.30) than at L4–5 (CV=0.18). The L4–5 facet joint orientation had a weak but significant correlation with the CSA of erector spinae (r=0.40; p=0.031). The CSA of the multifidus had no relationship with the facet joint orientation at the L4–5 (r=0.19; p=0.314) and the L5–S1 level (r=0.19; p=0.312). CONCLUSIONS: The lumbar facet joint orientation was found to have a wide variation, particularly at the L5–S1 in the Asian adult population, and the facet joint orientation had a relationship with the CSA of the erector spinae at the L4–5.

Significance of the Pars Interarticularis in the Cortical Bone Trajectory Screw Technique: An In Vivo Insertional Torque Study

STUDY DESIGN: Retrospective study. PURPOSE: Cortical bone trajectory (CBT), a more medial-to-lateral and shorter path than the traditional one for spinal fusion, is thought to be effective for severely degenerated vertebrae because screws are primarily stabilized at the posterior elements. We evaluated the efficacy of this approach through in vivo insertional torque measurement. OVERVIEW OF LITERATURE: There has been only one prior in vivo study on CBT insertional torque. METHODS: Between January 2013 and April 2014, a total of 22 patients underwent posterior lumbar fusion using the CBT technique. The maximum insertional torque, which covers the radial strength needed for insertion, was measured for 113 screws, 8 of which were inserted for L5 spondylolysis. The insertional torque for cases with (n=8) and without (n=31) spondylolysis of L5 were compared using one-way analysis of variance (ANOVA). To evaluate vertebral degeneration, we classified 53 vertebrae without spondylolysis by lumbar radiography using semiquantitative methods; the insertional torque for the 105 screws used was compared on the basis of this classification. Additionally, differences in insertional torque among cases grouped by age, sex, and lumbar level were evaluated for these 105 screws using ANOVA and the Tukey test. RESULTS: The mean insertional torque was significantly lower for patients with spondylolysis than for those without spondylolysis (4.25 vs. 8.24 in-lb). There were no statistical differences in insertional torque according to vertebral grading or level. The only significant difference in insertional torque between age and sex groups was in men <75 years and women ≥75 years (10 vs. 5.5 in-lb). CONCLUSIONS: Although CBT should be used with great caution in patient with lysis who are ≥75 years, it is well suited for dealing with severely degenerated vertebrae because the pars interarticularis plays a very important role in the implementation of this technique.

Compression Myelopathy due to Proliferative Changes around C2 Pars Defects without Instability

We report a case with compression myelopathy due to proliferative changes around the C2 pars defects without instability. A 69-year-old man presented with progressive clumsy hands and spastic gait. Plain radiographs showed bilateral spondylolysis (pars defects) at C2 and fusion between C2 and C3 spinous processes. Dynamic views revealed mobility through the pars defects, but there was no apparent instability. Computed tomography showed proliferative changes at the pars defects, which protruded into spinal canal. On magnetic resonance imaging, the spinal cord was compressed and intramedullary high signal change was found. A diagnosis of compression myelopathy due to proliferative changes around the C2 pars defects was made. We performed posterior decompression. Postoperatively, symptoms have been alleviated and images revealed sufficient decompression and no apparent instability. In patients with the cervical spondylolysis, myelopathy caused by instability or slippage have been periodically reported. The present case involving C2 spondylolysis is extremely rare.

Multilevel Thoracolumbar Spondylolysis with Spondylolisthesis at L4 on L5

A 24-year-old male patient was initially evaluated for persistent back pain. The visual analogue scale (VAS) score was 7 points. Physical examination revealed a decreased range of lumbar spinal motion, which caused pain. Simple X-ray revealed Meyerding grade 1 spondylolisthesis at L4 on L5, with mild dome-shaped superior endplate and consecutive multilevel spondylolysis at T12-L5. Standing anteroposterior and lateral views of the entire spine revealed normal balance of sagittal and coronal alignment. A computed tomography scan revealed bilateral spondylolysis at T12-L4, left unilateral spondylolysis at L5, and spina bifida at L5 to sacral region. Magnetic resonance imaging revealed mild dural ectasia at the lumbar region. Due to the absence of any neurological symptoms, the patient was managed conservatively. He was rested a few weeks with corset brace and physiotherapy. After treatment, his back pain improved, VAS score changed from 7 to 2, and he was able to return to normal activity.

Unilateral Pedicle Fracture Accompanying Spondylolytic Spondylolisthesis

Unilateral pedicle stress fracture accompanying spondylolytic spondylolisthesis is rare even in the elderly. Most are associated with major trauma, previous spine surgery, or stress-related activity. Here, the authors describe an unique case of unilateral pedicle fracture associated with spondylolytic spondylolisthesis at the L5 level, which was successfully treated by posterior lumbar interbody fusion with screw fixation at the L5-S1 level. As far as the authors' knowledge, no such case has been previously reported in the literature. The pathophysiological mechanism of this uncommon entity is discussed and a review of relevant literature is included.

Radiographic Assessment of Effect of Congenital Monosegment Synostosis of Lower Cervical Spine between C2-C6 on Adjacent Mobile Segments

STUDY DESIGN: A prospective radiographic study of cervical spine with congenital monosegment fusion. PURPOSE: To evaluate the effect of cervical synostosis on adjacent segments and the vertebral morphology. OVERVIEW OF LITERATURE: There are numerous clinical studies of adjacent segment disease (ASD) after monosegment surgical fusion. However, there was no report on ASD in the cervical spine with congenital monosegment synostosis. METHODS: Radiograms of 52 patients, aged 5 to 90 years, with congenital monosegment synostosis (CMS) between C2 and C6, who complained of neck/shoulder discomfort or pain were studied. 51 were normally aligned and one was kyphotically aligned. RESULTS: Spondylosis was not found in the patients below 35 years of age. Only 12 out of 24 patients with normally aligned C2-3 synostosis had spondylosis in 19 more caudal segments, and only one at C3-4. A patient with kyphotic C2-3 had spondylolysis at C3-4. In 8 patients with C3-4 synostosis, spondylosis was found in only 9 caudal segments (4 at C4-5, 4 at C5-6, and 1 at C6-7). The caudate C4-5 disc was the most liable to degenerate in comparison with other caudate segments. Caudal corporal flaring and inwaisting of the synostotic vertebra were the features that were the most evident. In 2 of 9 C4-5 and 7 out of 10 C5-6 synostosis patients, spondylosis was found at the two adjacent cephalad and caudate segments, respectively. Only corporal inwaisting without flaring was found. In all cases, spondylosis was confined to the adjacent segments. More advanced spondylosis was found in the immediate caudal segment than the cephalad one. CONCLUSIONS: It is concluded that spondylosis at the mobile segments in a synostotic spine is thought to be a fusion-related pathology rather than solely age-related disc degeneration. Those data suggested that CMS definitely precipitated the disc degeneration in the adjacent segments.

Lumbar Spondylolysis and Spondylolytic Spondylolisthesis: Who Should Be Have Surgery? An Algorithmic Approach

Lumbar spondylolysis and spondylolisthesis are common spinal disorders that most of the times are incidental findings or respond favorably to conservative treatment. In a small percentage of the patients, surgical intervention becomes necessary. Because too much attention has been paid to novel surgical techniques and new modern spinal implants, some of fundamental concepts have been forgotten. Identifying that small but important number of patients with lumbar spondylolysis or spondylolisthesis who would really benefit from lumbar surgery is one of those forgotten concepts. In this paper, we have developed an algorithmic approach to determine who is a good candidate for surgery due to lumbar spondylolysis or spondylolisthesis.