Objective To provide evidence-based therapeutic schedule for an adult patient with Lumber Isthmic Spondylolisthesis grading II. Methods Based on fully assessing the patient’s conditions, the clinical problems were put forward according to PICO principles. Such database as The Cochrane Library (2005 to April 2011), DARE (April 2011), CENTRAL (April 2011), MEDLINE (April 2011), EMbase and CBM were searched to collect high quality clinical evidence, and then we told a patient information about treatment plans. The plan was chosen by the patient for she knew her conditions and the plans. Results We included 1 meta-analysis, 3 randomized controlled trials, 5 systematic reviews and 1 prospective study on the natural course of isthmic spondylolisthesis were included. Literature evidence indicated that the prognosis of isthmic spondylolisthesis was good. Surgery should be selected when there was neither no remission of symptom, nor progression of lumber olisthy with conservative treatment. The long-term effect of surgery may be good, but it cannot change the natural course of the disease. Based on literature evidence, the patient chose the conservative treatment. After one year’s treatment the patient recovered, her sciatica relieved, and CT showed no progression of lumber olisthy. Conclusion Patient with low grand isthmic spondylolisthesis chose conservative treatment may achieves good effects, whereas on the process of the treatment, regular follow-up to monitor the progression of lumber olisthy should be conducted.
ObjectiveTo compare the effectiveness of treatment of isthmic spondylolisthesis between two different fusion surgeries combined with pedicle screw fixation system. MethodsA retrospectively analysis was made on the clinical data of 98 patients with lumbar isthmic spondylolisthesis treated between February 2009 and May 2012. Of 98 cases, 53 underwent posterior lumbar interbody fusion (PLIF) combined with internal fixation (group A), and 45 underwent posterolateral fusion (PLF) with internal fixation (group B). There was no significant difference in gender, age, disease duration, segmental lesions, and degree of spondylolisthesis between 2 groups (P>0.05). The operation time, intraoperative blood loss, reduction rate of spondylolisthesis, reduction loss rate, fusion rate, intervertebral space height, Japanese Orthopedic Association (JOA) score, and the recovery rate of JOA score were compared between 2 groups. ResultsThe operation time and intraoperative blood loss of group A were significantly higher than those of group B (P<0.05). Dural tear occured in 4 cases of group A and 1 case of group B during operation; 6 cases had radicular symptoms after operation in group A; incision infection was found in 1 case of 2 groups respectively. The follow-up time was 24-36 months in group A and was 26-40 months in group B. No significant difference was found in the JOA score at preoperation and 2 weeks after operation between 2 groups (P>0.05). The JOA score and the recovery rate of JOA score of group A were significantly better than those of group B at 2 years after operation (P<0.05). X-ray film showed that the reduction rate of group A was significantly higher than that of group B after 2 weeks of operation (P<0.05); the reduction loss rate of group A was significantly lower than that of group B after 2 years after operation (P<0.05). The intervertebral space height of group A was significantly higher than that of group B at 2 weeks and 2 years after operation (P<0.05). The fusion rate of group A was significantly better than that of group B at 2 years after operation (P<0.05). ConclusionPLIF can achieve a greater degree of reduction, better restore disc height, and lumbar curvature than PLF. PLIF is superior to PLF in maintaining intervertebral height after operation. And PLIF has higher fusion rate, restores the stability of the spine in a greater extent, and it also can achieve a better long-term outcome.
目的:探讨使用Moss Miami系统经骶棘肌肌间隙入路在APERTURE工具的引导下微创治疗腰椎滑脱症的疗效。方法:20例腰椎滑脱症患者(男11例,女9例),年龄30～65岁(平均40岁)。其中退变性14例、峡部裂5例、腰椎间盘突出合并钙化1例;Ⅰ度滑脱15例,Ⅱ度滑脱5例。滑脱部位:L4滑脱14例,L5滑脱6例,采用全麻俯卧位下经下腰部正中小切口(5cm),经双侧骶棘肌肌间隙入路在APERTURE工具的引导下放置Moss Miami系统进行复位固定和椎体间及后外侧植骨融合。结果:本组患者术中在C臂X光机监视,经骶棘间隙放置Moss Miami固定系统简单易行,切口较小、显露好、出血少,对骶棘肌等软组织造成的损伤轻,复位固定效果满意。术后经6月随访表明:本组患者腰腿痛等临床症状缓解,X线片显示滑脱复位无丢失、植骨融合良好、内固定器械无松动及断裂。结论:在C臂X光机监视下,采用Moss Miami经骶棘肌肌间隙入路在APERTURE工具的引导下治疗腰椎滑脱症具有切口小、肌肉软组织损伤轻、出血少、固定器械放置简单易行等优点,有利于患者术后康复。
Objective To investigate the effect of the sagittal alignment of the spine and pelvis after surgical posterior intervertebral fusion combined with pedicle screw fixation for low-grade isthmic lumbar spondylolisthesis, and to assess the effectiveness. Methods Between October 2009 and October 2011, 30 patients with low-grade isthmic spondylolisthesis underwent surgical posterior intervertebral fusion combined with pedicle screw fixation, and the clinical data were retrospectively reviewed. There were 14 males and 16 females with an average age of 56.7 years (range, 48-67 years). The pre- and post-operative radiographic parameters, such as percentage of slipping (PS), intervertebral space height, angle of slip (AS), thoracic kyphosis (TK), thoracolumbar junction angle (TLJ), sagittal vertical axis (SVA), lumbar lordosis (LL), spino-sacral angle (SSA), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI) were measured. The functional evaluation was made using the Oswestry Disability Index (ODI). Pearson correlation were used to investigate the association between all parameters and ODI score. Results PS, intervertebral space height, AS, and ODI were improved significantly compared with properative ones (P lt; 0.05). Significant differences were found in the other parameters between pre- and post-operation (P lt; 0.05) except TLJ and TK. The alteration of SVA showed significant correlation with the changes of PS, PI, PT, LL, SS, AS, SSA, and ODI. The alteration of SSA showed significant correlation with the changes of PS, PI, LL, SS, AS, PT, and ODI. Conclusion Surgical posterior intervertebral fusion combined with pedicle screw fixation for low-grade isthmic spondylolisthesis can effectively improve and maintain the spinal sagittal parameters. SVA and SSA are adequate to evaluate pre-and post-operative balance. The good clinical outcome is closely related with the improved of SVA and SSA.
Objective To analyze the effectiveness of combined treatment of lumbar spondylolisthesis with MED, Quadrant, and Sextant-R systems. Methods Between August 2006 and June 2011, 35 patients with lumbar spondylolisthesis were treated, including 11 cases of isthmic spondylolisthesis and 24 cases of degenerative spondylolisthesis. There were 25 males and 10 females, with a mean age of 55 years (range, 33-71 years). The mean disease duration was 37 months (range, 8-75 months). Spondylolisthesis occurred at L4, 5 level in 21 patients and at L5, S1 level in 14 patients. According to Meyerding classification, 35 cases were rated as dergee I. The minimally invasive surgeries were performed by paraspinal muscle approach; Quadrant system was used for decompression and fusion at severe side, MED system for windowing of lamina at mild side, and Sextant-R system for fixation and reduction. Visual analogue scale (VAS) score was used to evaluate pain, Oswestry disability index (ODI) to evaluate clinical outcomes, spondylolishesis ratio and intervertebral height to evaluate spondylolisthesis reduction. Results Lumbar continuous thin layer CT at postoperation showed that no pedicle screw invaded spinal canal and intervertebral fusion device was at good position. Incisions healed by first intention. All patients were followed up 18-38 months (mean, 26 months). All patients got bone fusion and had no internal fixation failure by radiologic examination at 1 year after operation. Low back pain was relieved, lumbar function improved obviously, and satisfactory reduction of spondylolisthesis was obtained. At 2 weeks and 1 year after operation, the VAS score, ODI score, spondylolisthesis ratio, and intervertebral height were significantly improved when compared with preoperative ones (P lt; 0.05). VAS score and ODI score showed significant differences (P lt; 0.05) between at 2 weeks and 1 year after operation. Spondylolisthesis ratio and intervertebral height showed no significant difference (P gt; 0.05) between at 2 weeks and at 1 year after operation. Conclusion Minimally invasive surgical management for lumbar spondylolisthesis via MED, Quadrant, and Sextant-R systems is a safe and effective surgical technique. However, its indications should be well considered.
Objective To investigate the technique of reduction by posterior approach for severe spondylolisthesis, and to discuss the method to prevent nerve stretch injury. Methods Between July 2007 and April 2011, 17 patients with severe spondylolisthesis underwent reduction, fixation, and fusion by posterior approach. There were 2 males and 15 females with a median age of 15 years (range, 8-67 years) and a median disease duration of 18 months (range, 5 months-16 years and 4 months). The level of spondylolisthesis was at L4 in 1 case and L5 in 16 cases; the spondylolisthesis was at degree III in 12 cases and degree IV in 5 cases according to Meyerding classification. There were 16 cases of developmental spondylolisthesis (high- dysplastic and low-dysplasia spondylolisthesis in 9 and 7 cases, respectively) and 1 case of traumatic spondylolisthesis; 16 cases of developmental spondylolisthesis at L5 level included 6 cases of type 4, 9 case of type 5, and 1 case of type 6 according to Spinal Deformity Study Group (SDSG) classification. All cases underwent posterior spinal decompression, Schanz screw fixation for the slipped vertebrae, the intervertebral and posterolateral fusion and reduction of the slipped vertebrae, and correction of the lumbosacral kyphosis. The reductive degree of slipped vertebrae was modulated according to the strain of exiting spinal root. The slip degree should be reduced within Meyerding degree II. The anteroposterior and lateral radiographs of whole spine were taken in a standardized standing position to observe the correction of displacement severity and lumbosacral angle. The nerve function and pain score of lower extremity were evaluated by neurological Frankel grade and visual analogue scale (VAS). Bony fusion was assessed by followed-up CT three-dimentional reconstruction. Results Exiting nerve root paralysis occurred in 1 case after operation, and released at 4 weeks after operation; no aggravation of nerve damage was observed in the other patients. The incisions primarily healed. All the patients were followed up 12-48 months (mean, 25 months). The slip percentage, the lumbosacral angle, and VAS score of lower extremity were improved from 72% ± 10%, (18.2 ± 3.5)°, and 7.0 ± 1.5 at preoperation to 12% ± 6%, ( — 7.3 ± 2.9)°, and 1.5 ± 1.3 at 12 months after operation respectively, all showing significant differences (P lt; 0.05). Osteosynthesis was seen at the bone grafting area by CT three-dimentional reconstruction at 12 months after operation. No breakage of screw and rod or reduction loss occurred. Conclusion It can obtain satisfactory clinical result to use spinal canal decompression by posterior approach, the Schanz screw fixation of the slipped vertebrae, the intervertebral and posterolateral fusion for severe spondylolisthesis. The risk of nerve stretch injury can be prevented by choosing the lowest height of intervertebral cage, modulating the reductive degree of slipped vertebrae according to the strain of exiting spinal root, and correcting lumbosacral kyphosis.
Objective To investigate the relationship between the volume of bone-graft and fusion efficacy in posterior lumbar interbody fusion and internal fixation of spondylolisthesis. Methods Between May 2004 and June 2007, 79 patients with spondylolisthesis were treated with posterior lumbar interbody fusion and internal fixation. The patients were randomly divided into 3 groups according to the volume of bone-graft for interbody fusion: group A (n=27), 5 bone granules/ cm3 on average; group B (n=26), 11 bone granules/cm3 on average; and group C (n=26), 25 bone granules/cm3 on average. There was no significant difference in gender, age, disease duration, affected segment, and the degree of vertebral slip among 3 groups (P gt; 0.05). The volume of bone-graft, the fusion rate, the loss of intervertebral height, and the incidence of internal fixation failure were compared among 3 groups. Results All cases were followed up 24-43 months (mean, 35 months). There were significant differences in volume of bone-graft among 3 groups (P lt; 0.05). There was no significant difference in total volume of bone-graft and Cage height among 3 groups (P gt; 0.05). The Oswestry disability index (ODI) and visual analogue scale (VAS) scores of low back pain and leg pain at last follow-up were significantly decreased when compared with preoperative scores in 3 groups (P lt; 0.05); but no significant difference was found among 3 groups (P gt; 0.05). The fusion rate was significantly higher in group B than in groups A and C, and in group A than in group C at 1 and 2 years after operation (P lt; 0.05). The change values of the intervertebral height were (2.2 ± 1.4), (0.8 ± 1.3), and (2.3 ± 1.6) mm respectively in groups A, B, and C; it was significantly lower in group B than in groups A and C (P lt; 0.05). The degree of vertebral slip at immediately after operation and last follow-up was significantly improved when compared with preoperative one in 3 groups (P lt; 0.05); the loss of vertebral slip in group B was significantly lower than that in groups A and C at last follow-up (P lt; 0.05). After operation, nail breaking occurred in 1 case (3.7%) of group C at 1 year, depinning in 1 case (3.8%) of group A at 2 years, and no nail breaking or depinning in group B. There was no significant difference in the incidence of internal fixation failure among 3 groups (χ2=3.950, P=0.604). Conclusion The application of bone-graft with middle volume (11 bone granules/cm3 on average) in internal fixation and posterior lumbar interbody fusion has a good imageology outcome, which can increase the fusion rate and decrease the loss of intervertebral height.
Objective To analyze the clinical features and preliminary outcome of posterior operation for traumatic lumbar spondylolisthesis. Methods The clinical data of 11 patients with traumatic lumbar spondylolisthesis who underwent surgeries between January 2008 and June 2012 were retrospectively analyzed. There were 6 male and 5 female patients, aged from 13 to 60 years with a median age of 38 years. The mechanism of injury included heavy pressure injury in 4 cases, falling injury from height in 4 cases, and traffic accident injury in 3 cases. The time of injury to operation was between 3 days and 13 years (median, 20 days). According to Frankel neurological function grading, 2 patients were rated as grade E, 4 as grade D, 3 as grade C, and 2 as grade B before operation; according to Meyerding spondylolisthesis grading, 4 cases were classified as degree I, 4 as degree II, 2 as degree III, and 1 as degree IV preoperatively. The affected segments included L4 in 3 and L5 in 8 patients. The surgical fixation segments were L4, 5 in 2 patients, L5, S1 in 7, and L4-S1 in 2. Eight patients underwent circumferential fusion, while 3 patients underwent posterolateral fusion. The reduction of spondylolisthesis and bone graft fusion were assessed on X-ray films and three-dimensional CT scans during follow-up. The clinical outcomes were evaluated by visual analogue scale (VAS) and Oswestry disability index (ODI) scores. Results All patients achieved primary healing of incision after operation. And all patients were followed up 6-40 months with a median time of 12 months. There was no pulling-out or breaking of internal fixation. The fusion rate was 100% on three-dimensional CT scans, and the fusion time was 3-6 months (mean, 4.5 months). The spondylolisthesis was degree 0 in 10 cases and degree I in 1 case according to Meyerding grading, showing significant difference when compared with preoperative spondylolisthesis grading (Z= — 2.979, P=0.003). The Frankel neurological function grading were E in 6, D in 3, and C in 2 at last follow-up, which were significantly improved when compared with preoperative one (Z= — 2.271, P=0.014). At 1 week after operation and last follow-up, VAS and ODI scores were significantly improved when compared with the preoperative scores (P lt; 0.05); however, no significant difference was found between at 1 week and at last follow-up (P gt; 0.05). Conclusion If lumbar X-ray films suggest multiple fractures of transverses in emergency combined with the mechanism of injury, it bly indicates the diagnosis of traumatic lumbar spondylolisthesis, moreover earlier decompression and fusion can provide the recovering of the neurological function and satisfactory preliminary effectiveness in these patients.
Objective To evaluate the effect of posterior lumbar interbody fusion (PLIF) using single incision via MAST Quadrant retractor in the management of lumbar spondylolisthesis. Methods From July 2008 to June 2009, 20 cases of lumbar spondylolisthesis were treated with posterior lumbar interbody fusion via MAST Quadrant retractor using single incision,including 2 cases of degenerative spondylolisthesis and 18 cases of isthmic spondylolisthesis. There were 8 males and 12 females aged from 34 to 62 years (average 45.5 years). The disease course was 1 to 6 years (mean 34.5 months). The spondylol isthesis locations were L4,5 in 8 cases and L5, S1 in 12 cases. According to Meyerding classification, all cases were classified as degree I. The Visual Analogue Scale (VAS) score was (6.6 ± 1.2) points. The operative time, the blood loss, and the therapeutic effects were recorded. Results The operative time was (155 ± 23) minutes and the amount of blood loss was (360 ± 102) mL. The hospitalization time were (12.0 ± 3.4) days. All incisions healed by first intention. X-ray films showed spondylolisthesis reduction immediately after operation. All patients were followed up 14.3 months on average (from 9 to 20 months). The VAS score decreased to (1.6 ± 2.3) points at the last follow-up, showing significant difference when compared with that of preoperation (P lt; 0.05). The X-ray films showed that lumbar interbody fusion was achieved in all the patients. No lossening, breakage, and displacement of pedicle screw fixation was observed. According to Nakai standard, the results were excellent in 18 cases and good in 2 cases at the last follow-up. Conclusion As long as the indication is strictly chosen, PLIF via MAST Quadrant retractor is a safe, effective, and minimally invasive surgical technique in treating lumbar spondylolisthesis.