Neurosurgery notes/Spine/Deformity/Thoracic and lumbar deformity/Kyphosis/Spondylolisthesis/Degenerative spondylolisthesis

Degenerative spondylolisthesis

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Spondylolisthesis
  • Numbers
    • middle aged and elderly population
    • More common in
      • females
      • patients of African descent.
  • Pathology
    • Secondary to degenerative disc disease → additional strain on the facet joints.
    • Most frequently at L4/ 5
      • Due to sagittal orientation of the L4/ 5 facets in comparison to the coronal orientation of the L5/ S1 facets which resist anterior translation.
  • Clinical presentation
    • Similar to that of lumbar canal stenosis
    • Radicular pain resulting from compression of the L5 nerve roots by
      • the slipped inferior articulating process,
      • hypertrophied facet,
      • rolling broad based disc.
    • Low back pain
      • Unlikely causal, likely correlation
      • Chun 2017
        • patients with LBP have less lumbar lordosis
    • CES
      • is rare but may present subacutely with a coexisting acute disc herniation.
  • Natural history
    • Relatively benign condition
    • Progression rates are as low as 25% with slippage rarely progressing beyond one Meyerding grade.
  • Management
    • Non- operative treatment
      • effective pain management
      • physiotherapy.
      • Epidural or perineural blockade
        • when radicular symptoms exist.
    • Surgical management
      • Indicated
        • symptomatic patients following an adequate trial of optimal conservative measures.
      • Several studies suggest superior functional and pain outcomes in surgical versus medically treated patients.
      • The decision to decompress alone or decompress and fuse in the context of a degenerative spondylolisthesis remains controversial and should be based on individual factors such as
        • age,
        • comorbidities,
        • bone quality,
        • back pain suggestive of instability,
        • dynamic radiographs,
        • degree of slip,
        • intraoperative findings of segmental instability.
      • To fuse or not to fuse
        • Prof Rothenfluh: Britspine 2023/SBNS 2022 Decompression seems primary treatment for DS, unless...
          • Foraminal stenosis (foraminal nerve compression exclusion in NORDSTEN trial)
          • More than one level disease I spondylolisthesis
          • Revision surgery after previous decompression for spondylolisthesis
          • Dynamic/mobile spondylolisthesis
          • Asymmetric collapse, coronal deformity
          • Sagittal malalignment
        • Specific mechanical indications has not been studied yet in RCT
          • Fusion angles
          • Spino-pelvic alignment
          • Mobile spondylolisthesis
          • Foraminal stenosis
          • Facet Joint orientation
        • Evidence not for fixation
          • NORDSTEN-DS trial:
            • Fusion is not superior to Decompression only
            • Decompression 12.5% alone has greater operation rates than decompression + fusion 9.1% in 2 years.
            • Hellum 2023: A secondary analysis of NORDSTEN trial
              • Even looking at the below factors, they did not predict whether a patient will have an at least 30% ODI improvement (success)
                • Spondylolisthesis, ≥20% slippage
                • Instability, ≥10 degrees and or ≥3 mm slippage
                • Facet joint fluid, ≥2 mm
                • Disc height, mm
                • Lumbar lordosis, angle
                • Pelvic incidence, angle
                • Facet joint angulation, angle
              • Two factors that predict at least 30% ODI improvement were less comorbidity and more leg pain.
          • Swedish SSSS trial
            • Fusion is not superior to Decompression only
            • Fixation + decompression
              • Longer operating time
              • Greater blood loss
              • Greater cost
            • Decompression 21% alone has similar additional operation rates than decompression + fusion 22% in 6.5 years.
            • This is even true for >7mm slip
          • SLIP trial:
            • No difference in ODI but SF36 was better in fusion
            • Greater reoperation in decompression 34% vs fusion 14%
            • Fusion
              • Greater blood loss
              • Longer hospital stay
        • Fixation in situ: still unclear
          • Wang et al 2023
            • N 704
            • Meta analysis of 5 studies: 2 RandomCT and 2 ProspectiveCT and 1 Retro
            • Reduction Fusion vs fusion in situ
            • Fusion in situ has shorter surgery time
            • No difference in
              • VAS/NRS
              • ODI
              • JOA score
              • Blood loss
              • Complication rate
              • Fusion rate
              • Reoperation rate
          • If do not respect PI and LL relationship there will be an increases Adjacent segment disease (ASD)
            • Rothenfluh 2015
                • notion image
              • (PILL = PI-LL, ASD 12.5 ± 16.7° vs. CTRL 3.4 ± 12.1°, p = 0.001).
              • A cut-off value of 9.8° was determined by logistic regression
              • a type A (PILL <10°) and a type B (PILL >10°) alignment according to pelvic incidence-lumbar lordosis mismatch.
                • Type A
                25.5 % of patients underwent revision surgery for adjacent segment disease
                Type B
                78.3 % of patients had revision surgery.
          • Rhee et al 2017:
            • Restoration of focal lumbar lordosis and restoration of sagittal balance for the operative treatment of single-level lumbar degenerative spondylolisthesis, whether intentional or not, does not seem to yield any clinical improvement
            • Sagittal balance improvement is often observed without intentional intraoperative reduction since patients no longer compensate by leaning forward and retroverting their pelvis
          • Caelers 2024
            • For patients with single-level spondylolisthesis, TLIF is non-inferior to PLIF in terms of clinical effectiveness.
            • Disability (measured with ODI) did not differ over time between groups