Objective
To review the research progress of the risk factors for slip progression and the pathogenesis of lumbosacral spondylolisthesis, and to discuss the value of Spinal Deformity Study Group (SDSG) classification system for lumbosacral spondylolisthesis.
Methods
Recent articles about the risk factors for slip progression and the pathogenesis of lumbosacral spondylolisthesis were reviewed and comprehensively analyzed with SDSG classification system of lumbosacral
spondylolisthesis.
Results
Pelvic incidence (PI) is the key pathogenic factor of lumbosacral spondylolisthesis. The Meyerding grade of slip, PI, sacro-pelvic balance, and spino-pelvic balance not only are the fundamental risk factors of slip progression, but also are the key factors to determine how to treat and influence the prognosis. Therefore, compared with Wiltse, Marchetti-Bartolozzi, and Mac-Thiong-Labelle classification systems of lumbosacral spondylolisthesis, SDSG classification based on these factors mentioned above, has better homogeneity between the subjects of subgroup, and better reliability, moreover, could better guide operative plan and judge the prognosis.
Conclusion
It is suggested that the SDSG classification system should be the standard classification for lumbosacral spondylolisthesis for the clinical and research work.
Objective To evluate the clinical outcome of autograftsof ilium and interbody fusion cage or bone morphogenetic protein(BMP)／artificial bone material／ cage in treating lumbar spondylolisthesis. Methods From January 1997 to January 2004，114 patients with lumbar spondylolisthesis were treated with posterior lumbar interbody fusion and pedicle screw fixation． There were 45 males and 69 females with an average age of 43 years ranging from 32 to 61 years. Of 114patients, 85 cases were classified as degree Ⅰ, 24 cases as degree Ⅱ and 5 cases as degree Ⅲ. The patients were divided into three groups accordingto the material used for interbody fusion: autografts of ilium (group A, n=42), interbody fusion cages(group B, n=36), and BMP／artificial bone material／ cage (group C, n=36)．The clinical and radiographic results of the patients were compared among three groups． Results All patients were followed from 13 to 30 months with an average of 15 months． There were no statistically significant differences in surgical time, blood loss, and disc space height of preoperation(P＞0.05) among three groups. No severe complication occurred in the three groups(P＞0.05). The excellent and good rates in groups A，B and C were 81.0％, 80.6％, and 83.3％ respectively, showing no statisticallysignificant difference(P＞0.05)．The fusion rate of group C(97.0%) was significantly higher than those of group A(81.0%) and group B(83.3%) (P＜0.05) after 1 year of operation．And the average loss of disc space height in groups B and C was significantly lower than that in group A(P＜0.05). Conclusion Higher fusion rate and lower loss of disc space height can beobtained in treating lumbar spondylolisthesis with BMP／artificial bone materiel.It is an effective method in the treatment of spondylolisthesis.
To investigate the shortsegment pedicle screw in treating degenerative L4 spondylolisthesis and the relationship of the preliminarily bending degree of the titanium rod with the lumbar lordosisangle, the slipping angle and the slipping percentage and to evaluate the clinical coincidence and curative effects of the preliminarilybent rod. MethodsFrom September 2005 to March 2007, 31 female patients (age, 40-70 years; average, 58.3 years) were admitted for surgical treatment of their L4 degenerative spondylolisthesis (MeyerdingⅠ°, Ⅱ°)． Their lumbar lordosis angle （x1）, slipping angle (x2), and slipping percentage (x3) were measured in the L4,5 segment before operation. During the operation, the titanium rod bent beforehand according to the corresponding standards was inserted. The angle of the bent rod (Y) was measured, and then the multiple linear regression equation was established. The regression equation was applied to the surgical treatment of the 30 patients.Results According to the criteria in the JOA scoring system, the 31 patients had scores of 8.300± 1.080 and 26.916±1.859 before operation and after operation, respectively. There was a significant difference between before operation and after operation（Plt;0.05）. The established multiple linear regression equation was as follows:Y=0.1390-0.327logx1+0.463x2+0.288x32．The operating time was 51.290±3.408 min in the 30 patients who underwent an insertion of the preliminarilybent rod during the operation; however, the operating time was 102.360±5.004 min in the 31 patients who underwent an insertion of the bent rod that was made based on experience during the previous operations. There was a significant difference in the operating time between the two kinds of the rods （Plt;0.05）. Estimated according to 90%, 95% and 99% of the areas under the normalcurve, the clinical coincidence rates in the preliminarily bending degrees of the titanium rod in the 30 patients were 80.00％，90.00％ and 96.67％, respectively.Conclusion The titanium rod that has been bent into a certain angle before operation according to the established criteria can definitely diminish its strain during operation and efficiently shorten the operating time．Thiskind of the titanium rod has a good coincidence in clinical application and can be effectively used in clinical practice.It is worth reference during the clinical operation.
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.
ObjectiveTo observe vertebral three-dimensional motion characteristics of adjacent segments in patients with symptomatic L4 isthmic spondylolisthesis (IS). MethodsFourteen symptomatic L4 IS patients who underwent surgery treatment (trial group) and 15 asymptomatic volunteers without back pain and other lesions of spine (control group) were recruited. There was no significant difference in gender, age, body mass index, and bone mineral density between the two groups (P>0.05). The three-dimensional reconstruction model of lumbar spine was acquired from the thin slice CT of the lumbar spine of the subjects by combining dual-X-ray fluoroscopy imaging system with spiral CT examination. The model was matched to the double oblique X-ray fluoroscopy images captured by dual-X-ray fluoroscopy imaging system at different active positions of the lumbar spine to reproduce the three-dimensional instantaneous of lumbar spondylolisthesis at different state of motion. The motion and relative displacement of adjacent segments (L3, 4 and L5, S1) of spondylolisthesis were measured quantitatively by establishing a three-dimensional coordinate system at the geometric center of the vertebral body. The results were compared with those of the control group. ResultsWhen L3, 4 in the control group were flexed flexion-extension, left-right twisting, and left-right bending, and when L5, S1 in the control group were flexed left-right twisting and left-right bending, the activity along the main axis of motion (main axis of motion) tended to increase compared with that along the corresponding coupled axis of motion (secondary axis of motion); however, this trend disappeared in the trial group, and the main and secondary movements were disordered. Because of the coronal orientation of the facet joints of L5, S1, the degree of motion along the main axis of motion decreased during flexion and extension, but this trend disappeared in the trial group. Compared with the control group, L3, 4 in the trial group exhibited displacement instability in flexion-extension, left-right twisting, and left-right bending (P<0.05); there was no significant difference in the relative displacement of L5, S1 intervertebral bodies along x, y, and z axes between the trial group and the control group in flexion-extension, left-right twisting, and left-right bending curvature (P>0.05). ConclusionPatients with symptomatic L4 IS have disorders of primary and secondary movement patterns in adjacent segments, while IS showed significantly displacement instability in L3, 4 and significantly decreased motion in L5, S1.
BJECTIVE: To discuss the clinical effect and the application of AF device fixation system and PROSPACE interbody fusion cage on treating lumbar spondylolisthesis. METHODS: Twenty-one cases of lumbar spondylolisthesis treated by operation from 1999 to 2002 were analyzed retrospectively (13 males and 8 females, 25-66 years old averaging 42 years). We had thorough decompression on the part of nerve compression and had replacement and fixation of the slippage vertebral body with the AF transpedicular screw/rod system so that the normal spine physiological curvature could be recovered, and then performed the posterolateral interbody fusion with implanting the PROSPACE filled with autograft bones. RESULTS: All the patients were followed up for 3 months to 3 years with an average of 15 months. The preoperation symptoms improved in 20 cases (95.2%). CONCLUSION: The combination of AF device fixation system and PROSPACE interbody fusion cage can relieve effectively nerve compression, recover the normal spinal physiological curvature, maintain the height of interbody and promote the nerve fusion. It is reliable and effective in the treatment of spondylolisthesis.
ObjectiveTo investigate the effectiveness of modified direction-changeable lumbar Cage in transforaminal lumbar interbody fusion (TLIF).MethodsA retrospective analysis was made of 161 patients with single segment L4 or L5 isthmic spondylolisthesis treated between January 2013 and December 2015. According to the implantation of Cage, they were divided into trial group (85 cases, modified direction-changeable lumbar Cage implanted in TLIF) and control group (76 cases, traditional nondirection-changeable Cage implanted in TLIF). There was no significant difference in the general data of gender, age, disease duration, slippage segment, and slippage grade between the two groups (P>0.05). The intraoperative implantation time of Cage, Cage position adjustments times, fluoroscopy times during implantation of Cage, fluoroscopy exposure time, and total operation time were recorded and compared between the two groups. Visual analogue scale (VAS) and Oswestry disability index (ODI) scores were used to evaluate the effectiveness of the patients before operation, and at 3, 6, and 12 months after operation, and the incidence of complications was recorded and analyzed. CT examinations were performed at 6 and 12 months after operation, and lumbar fusion was evaluated by Bridwell criteria.ResultsThe intraoperative implantation time of Cage, Cage position adjustments times, fluoroscopy times during implantation of Cage, fluoroscopy exposure time, and total operation time in trial group were significant less than those in control group (P<0.05). All the 161 patients were followed up 12-18 months (mean, 14.3 months). There was 1 case of dural sac tear in the trial group and 1 case of superficial infection in the control group; no complication such as dural tear and infection occurred in other patients. The fusion rate was 76.5% (64/85) in the trial group and 57.9% (44/76) in the control group at 6 months after operation, showing significant difference (χ2=6.44, P=0.02); at 12 months after operation, the fusion rate was 96.5% (82/85) in the trial group and 90.8% (69/76) in the control group (including 3 cases of Cage displacement and 4 cases of screw breakage), showing no significant difference in the fusion rate between the two groups (χ2=1.54, P=0.26). The VAS and ODI scores of the two groups decreased gradually at 3, 6, and 12 months after operation, and improved significantly when compared with those before operation (P<0.05). There was no significant difference in VAS and ODI scores between the two groups before and after operation (P>0.05).ConclusionBoth Cages can obtain the similar effectiveness. The modified direction-changeable lumbar Cage can significantly reduce the fluoroscopy times and radiation dose during TLIF, shorten the operation time, and effectively reduce the radiation exposure of patients and medical staff.
ObjectiveTo investigate the effectiveness of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) assisted with microscope in treatment of lumbar spondylolisthesis.
MethodsBetween January 2011 and June 2012, 52 patients with lumbar spondylolisthesis underwent MI-TLIF assisted with microscope. There were 29 males and 23 females with an average age of 46 years (range, 32-67 years). The median disease duration was 3.2 years (range, 3 months to 6 years). There were 38 cases of lumbar isthmic spondylolisthesis and 14 cases of degenerative spondylolisthesis; 12 cases had stenosis secondary to lumbar spondylolisthesis. The affected segments were L4, 5 (29 cases) and L5, S1 (23 cases). According to the Meyerding evaluating system, 24 cases were classified as degree I and 28 cases as degree Ⅱ. The visual analogue scale (VAS) score and Oswestry disability index (ODI)were used for clinical assessment, and the clinical effects were also analyzed by Macnab criterion at last follow-up. The radiographic data were used to evaluate reduction of spondylolisthesis, including slipping degree, slipping angle, and intervertebral space height. The fusion rate was assessed by Suk criterion.
ResultsThe operations were performed successfully in all patients. No dural tear or cerebrospinal fluid leakage occurred during operation. The average operation time was 105 minutes; the average intraoperative blood loss was 225 mL; the average postoperative drainage volume was 75 mL; and the average hospitalization days were 5.5 days. Superficial infection of incision occurred in 1 case and was cured after change dressing, and primary healing of incision was obtained in the others. All patients were followed up 12-26 months (mean, 18 months). No loosening, breakage, and displacement of pedicle screw and no Cage dislocation occurred by X-ray films after operation. The lumbar spondylolisthesis all got good correction. The three-dimensional CT showed continuous bone trabecula between centrums. The VAS score, ODI, and the slipping degree, slipping angle, and intervertebral space height were significantly improved at last follow-up when compared with preoperative ones (P<0.05). According to Macnab criterion at last follow-up, the results were excellent in 20 cases, good in 29 cases, and fair in 3 cases; the excellent and good rate was 94.2%. According to Suk criterion for fusion, 49 cases obtained complete fusion and 3 cases got possible fusion.
ConclusionAs long as indications are seized, MI-TLIF assisted with microscope is safe and reliable for treatment of lumbar spondylolisthesis (Meyerding dergee I or Ⅱ), and it has the advantage of less injury, less blood loss, less complications, and definite short-term effectiveness.
Objective
To explore the clinical application value of the spinal robot-assisted surgical system in mild to moderate lumbar spondylolisthesis and evaluate the accuracy of its implantation.
Methods
The clinical data of 56 patients with Meyerding grade Ⅰ or Ⅱ lumbar spondylolisthesis who underwent minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) between January 2017 and December 2017 were retrospectively analysed. Among them, 28 cases were preoperatively planned with robotic arm and percutaneous pedicle screw placement according to preoperative planning (group A); the other 28 cases underwent fluoroscopy-guided percutaneous pedicle screw placement (group B). There was no significant difference in gender, age, body mass index, slippage type, Meyerding grade, and surgical segmental distribution between the two groups (P>0.05). The screw insertion angle was measured by CT, the accuracy of screw implantation was evaluated by Neo’s criteria, and the invasion of superior articular process was evaluated by Babu’s method.
Results
One hundred and twelve screws were implanted in the two groups respectively, 5 screws (4.5%) in group A and 26 screws (23.2%) in group B penetrated the lateral wall of pedicle, and the difference was significant (χ2=9.157, P=0.002); the accuracy of nail implantation was assessed according to Neo’s criteria, the results were 107 screws of degree 0, 3 of degree 1, 2 of degree 2 in group A, and 86 screws of degree 0, 16 of degree 1, 6 of degree 2, 4 of degree 3 in group B, showing significant difference between the two groups (Z=4.915, P=0.031). In group B, 20 (17.9%) screws penetrated the superior articular process, while in group A, 80 screws were removed from the decompression side, and only 3 (3.8%) screws penetrated the superior articular process. According to Babu’s method, the degree of screw penetration into the facet joint was assessed. The results were 77 screws of grade 0, 2 of grade 1, 1 of grade 2 in group A, and 92 screws of grade 0, 13 of grade 1, 4 of grade 2, 3 of grade 3 in group B, showing significant difference between the two groups (Z=7.814, P=0.029). The screw insertion angles of groups A and B were (23.5±6.6)° and (18.1±7.5)° respectively, showing significant difference (t=3.100, P=0.003).
Conclusion
Compared to fluoroscopy-guided percutaneous pedicle screw placement, robot-assisted percutaneous pedicle screw placement has the advantages such as greater accuracy, lower incidence of screw penetration of the pedicle wall and invasion of the facet joints, and has a better screw insertion angle. Combined with MIS-TLIF, robot-assisted percutaneous pedicle screw placement is an effective minimally invasive treatment for lumbar spondylolisthesis.
Objective To compare the effectiveness of posterolateral approach lumbar interbody fusion assisted by one-hole split endoscope (OSE) and traditional posterior lumbar interbody fusion (PLIF) in the treatment of L4, 5 degenerative lumbar spondylolisthesis (DLS). Methods The clinical data of 58 patients with DLS who met the selection criteria admitted between February 2020 and March 2022 were retrospectively analyzed, of which 26 were treated with OSE-assisted posterolateral approach lumbar interbody fusion (OSE group) and 32 were treated with PLIF (PLIF group). There was no significant difference between the two groups in terms of gender, age, body mass index, Meyerding grade, lower limb symptom side, decompression side, stenosis type, and preoperative low back pain visual analogue scale (VAS) score, leg pain VAS score, Oswestry disability index (ODI), and the height of the anterior and posterior margins of the intervertebral space (P>0.05). The operation time, intraoperative blood loss, postoperative hospital stay, and complications were compared between the two groups. The low back pain and leg pain VAS scores and ODI before operation, at 1 month, 6 months after operation, and last follow-up, the height of anterior and posterior margins of the intervertebral space before operation, at 6 months after operation, and last follow-up, the modified MacNab criteria at last follow-up after operation were used to evaluate the effectiveness; and the Bridwell method at last follow-up was used to evaluate the interbody fusion. Results Both groups successfully completed the operation. Compared with the PLIF group, the OSE group showed a decrease in intraoperative blood loss and postoperative hospital stay, but an increase in operation time, with significant differences (P<0.05). In the OSE group, no complication such as nerve root injury and thecal sac tear occurred; in the PLIF group, there were 1 case of thecal sac tear and 1 case of epidural hematoma, which were cured after conservative management. Both groups of patients were followed up 13-20 months with an average of 15.5 months. There was no complication such as loosening, sinking, or displacement of the fusion cage. The low back pain and leg pain VAS scores, ODI, and the height of anterior and posterior margins of the intervertebral space at each time point after operation in both groups were significantly improved when compared with those before operation (P<0.05). Except for the VAS score of lower back pain in the OSE group being significantly better than that in the PLIF group at 1 month after operation (P<0.05), there was no significant difference in all indicators between the two groups at all other time points (P>0.05). At last follow-up, both groups achieved bone fusion, and there was no significant difference in Bridwell interbody fusion and modified MacNab standard evaluation between the two groups (P>0.05). Conclusion OSE-assisted posterolateral approach lumbar interbody fusion for L4, 5 DLS, although the operation time is relatively long, but the postoperative hospitalization stay is short, the complications are few, the operation is safe and effective, and the early effectiveness is satisfactory.
