The Importance of Proximal Fusion Level Selection for Outcomes of Multi-Level Lumbar Posterolateral Fusion

BACKGROUND: There are few studies about risk factors for poor outcomes from multi-level lumbar posterolateral fusion limited to three or four level lumbar posterolateral fusions. The purpose of this study was to analyze the outcomes of multi-level lumbar posterolateral fusion and to search for possible risk factors for poor surgical outcomes. METHODS: We retrospectively analyzed 37 consecutive patients who underwent multi-level lumbar or lumbosacral posterolateral fusion with posterior instrumentation. The outcomes were deemed either 'good' or 'bad' based on clinical and radiological results. Many demographic and radiological factors were analyzed to examine potential risk factors for poor outcomes. Student t-test, Fisher exact test, and the chi-square test were used based on the nature of the variables. Multiple logistic regression analysis was used to exclude confounding factors. RESULTS: Twenty cases showed a good outcome (group A, 54.1%) and 17 cases showed a bad outcome (group B, 45.9%). The overall fusion rate was 70.3%. The revision procedures (group A: 1/20, 5.0%; group B: 4/17, 23.5%), proximal fusion to L2 (group A: 5/20, 25.0%; group B: 10/17, 58.8%), and severity of stenosis (group A: 12/19, 63.3%; group B: 3/11, 27.3%) were adopted as possible related factors to the outcome in univariate analysis. Multiple logistic regression analysis revealed that only the proximal fusion level (superior instrumented vertebra, SIV) was a significant risk factor. The cases in which SIV was L2 showed inferior outcomes than those in which SIV was L3. The odds ratio was 6.562 (95% confidence interval, 1.259 to 34.203). CONCLUSIONS: The overall outcome of multi-level lumbar or lumbosacral posterolateral fusion was not as high as we had hoped it would be. Whether the SIV was L2 or L3 was the only significant risk factor identified for poor outcomes in multi-level lumbar or lumbosacral posterolateral fusion in the current study. Thus, the authors recommend that proximal fusion levels be carefully determined when multi-level lumbar fusions are considered.

Espondiloptose em atleta / Spondyloptosis in athlete

Os atletas adolescentes estão sob maior risco de lombalgia e lesões estruturais da coluna. A espondilólise é responsável pela maioria das lombalgias em jovens esportistas e raramente ocorre em adultos. Relatamos o caso de uma paciente de 13 anos, atleta de judô, que chegou a nosso serviço com quadro de cinco meses de lombalgia progressiva durante os treinos, sendo inicialmente atribuída a causas mecânicas, sem que houvesse uma investigação mais detalhada por métodos de imagem. Na admissão já apresentava deformidade lombar, postura antálgica e manobra de hiperextensão lombar em unipodálico positiva bilateralmente. Realizou-se investigação, que evidenciou espondiloptose, sendo, então, submetida a tratamento cirúrgico. Com base neste relato de caso, discutimos a abordagem diagnóstica de lombalgia em atletas jovens, uma vez que a queixa de lombalgia crônica pode ser marcador de uma lesão estrutural, a qual pode ser definitiva e trazer perda funcional irreversível.

The adolescent athletes are at greater risk of low back pain and structural spine injuries. Spondylolysis is responsible for the majority of back pain cases in young athletes, rarely occurring in adults. We report a case of a 13-year-old judo female athlete, who came to our service with 5 months of progressive low back pain during training which was initially attributed to mechanical causes, without any further investigation by imaging methods. At admission, the patient had lumbar deformity, antalgic posture and bilaterally positive unipodalic lumbar hyperextension maneuver. After a research which showed spondyloptosis, the patient underwent surgery. In this article, we discuss, based on this case report, the diagnostic approach to low back pain in young athletes, since the complaint of chronic back pain can be a marker of a structural lesion that may be permanent and bring irreversible functional loss.

Surgical treatment of isthmic spondylolisthesis with radicular pain in adults.

A common consensus has not yet been reached on surgical management of isthmic Spondylolisthesis especially regarding the optimal surgical procedure. This prospective study was carried to see the outcome of Posterolateral fusion with instrumentation without decompression. Eight consecutive patients, aged between 43 to 55 years, underwent primary surgery for isolated L4, L5 lumbar isthmic Spondylolisthesis of less than grade II that presented with radicular pain and exhibited instability on dynamic radiograph. The surgical procedure consisted of instrumentation with pedicle screws and rods (Moss Miami System) and posterolateral fusion in situ by placement of autogeneous bone graft, harvested from posterior iliac crest. Postoperatively Clinical and Radiological status were assessed and were graded according to Stauffer and Coventry method. The patients were followed up for one to three years. Radiological evidence of fusion was clearly evident by six months in all cases. Symptomatically all were relieved of radicular pain completely. One patient had recurrent backache due to causes unrelated to the illness of surgical procedure requiring occasional analgesic. No serious complication was encountered. This lead to conclusion that in adults of our population with low grade isthmic spondylolisthesis and radicular pain Instrumentation with Posterolateral fusion without decompression was sufficient to relieve symptoms.

Degenerative disk disease at lumbosacral junction: plain film findings and related MRI abnormalities.

Due to a wide range of normal disk space heights at lumbosacral (LS) junction, we conducted this study to evaluate how to diagnose degenerative disk disease (DDD) of LS junction and how much information we can obtain from plain radiography regarding this condition. We retrospectively reviewed lateral LS spine films and magnetic resonance (MR) imaging in 100 patients presented with low back pain. Anterior disk height (ADH) and posterior disk height (PDH) were directly measured from plain radiographs. Signs of DDD were recorded from both plain radiographs and MR imaging. We found that ADH < 11.3 mm or PDH < 5.5 mm indicate DDD at LS junction with 95 per cent confidence interval. When spondylolisthesis presented, disks were all degenerated. Endplate sclerosis had significant relative risk (p < 0.05) for lateral neural canal stenosis and disk herniation. No radiographic finding showed significant relative risk for nerve root compression.

Sacroplastía para el tratamiento de espondilolistesis severas L5-S1. Reporte de un caso / Sacroplasty for treatment of severe L5-S1 spondylolisthesis. A case report

La sacroplastía es el tratamiento que produce menor daño neurológico postoperatorio. Aquí se presenta el caso de una paciente de 35 años con diagnóstico de síndrome de cola de caballo, secundario a espondilosis con espondilolistesis grado III tratada con cirugía descompresiva mediante laminectomía, sacroplastía y corset lumbosacro. Los resultados mostraron la remisión del dolor, mejoría de la micción sin retención urinaria por lo que se recomienda este tratamiento