Degenerative Spondylolisthesis

Abstract

Study Design: A prospective cohort. Objective: The objective of this study was to develop a scoring system for lumbar degenerative spondylolisthesis (LDS) that would guide decision-making. Background: The management protocol for LDS has been under debate, with no guidelines. Most studies oversimplify LDS as a homogenous entity. Materials and Methods: A retrospective analysis of 131 patients who underwent surgery for LDS between July 2007 and October 2011 with a minimum follow-up of 3 years was carried out on the basis of clinical, radiologic, and technical factors. A scoring system was conceptualized. Clinical: back pain score—2, age younger than 70 years—1, high-demand activity—1. Radiologic: segmental kyphosis—1.5, segmental dynamic translation—1, disk height >50% of adjacent level—1, facet effusion—1, sagittal facet-orientation—1. Technical: feasibility to decompress without causing instability—1.5. Its reliability was ascertained by a univariate analysis. The benchmark was set at 5.5 according to the Youden Index. This was followed by a prospective study for reliability analysis between November 2011 and January 2017 of 52 patients who underwent stand-alone decompression in LDS with a minimum follow-up of 24 months. Outcomes were evaluated using the Oswestry Disability Index and the Visual Analog Scale. Interobserver variability was determined. None of the patients in the retrospective or prospective group had undergone any lumbar surgery previously. Results: The mean Oswestry Disability Index and Visual Analog Scale of both the groups in the retrospective and the stand-alone decompression groups in prospective studies showed significant improvement. The interobserver reliability was high, with a κ value of 0.847. Conclusions: The proposed scoring system helps view LDS as a heterogenous condition and assists in tailoring treatment for individual patients. For a select subgroup of patients with LDS, minimally invasive decompression (unilateral laminotomy and bilateral decompression using a minimally invasive surgery tubular retractor system) without fusion is adequate. Level of Evidence: Level III.

Magnetic Resonance Imaging Proxies for Segmental Instability in Degenerative Lumbar Spondylolisthesis Patients

“…They protect the disk from excessive shear and rotation, whilst guiding motion between two adjacent vertebrae 30. An association between sagittal orientation of the lumbar facet joints and LDS have been proposed by previous studies 6,14,31–33. According to Boden et al 14 the threshold for sagittal oriented lumbar facet joints are 45° at L4/L5.…”

“…30 An association between sagittal orientation of the lumbar facet joints and LDS have been proposed by previous studies. 6,14,[31][32][33] According to Boden et al 14 the threshold for sagittal oriented lumbar facet joints are 45°at L4/L5. We confirm that sagittal oriented facet joints are predictive of radiographic instability.…”

Decision-making Algorithm for the Surgical Treatment of Degenerative Lumbar Spondylolisthesis of L4/L5

“…He suggested that patients older than 70 years are more likely to undergo decompression without fusion because older patients tend to suffer from comorbidities, making them less tolerant of a fusion procedure. 13 Schneider et al 27 also showed that patient age was associated with the decision for fusion. In our population, there was no difference in age between both groups.…”

“…11,12 DA has been described as an alternative to fusion and an effective procedure, especially for patients without segmental hypermobility on dynamic lumbar radiographs. 13,14 In this context, it is a clinical challenge to identify the subgroup of patients who may benefit from an isolated decompression. Various factors might be considered when deciding whether to fuse, including patient demographics, symptom presentation, and radiographic parameters.…”

Commentary: Transforaminal Lumbar Interbody Fusion With Double Cages: 2-Dimensional Operative Video

“…Choice of surgical approach for LDS continues to be multifactorial, with significant controversy regarding not only decompression vs the addition of fusion but also regarding the ideal surgical approach. One group has implemented the use of a scoring system that includes clinical, radiographic, and technical variables to assist with tailoring the decision to add fusion to individual patients, 16 although this paradigm is not yet widely used. There is a need for continued study of the various fusion procedures with long-term outcomes to develop a more comprehensive set of guidelines for treating LDS.…”