峡部裂性腰椎滑脱症的手术治疗进展

峡部裂性腰椎滑脱症是一种常见的脊柱退行性疾病,严重影响人们的生活质量。目前腰椎滑脱的手术治疗指征已基本形成共识,针对该病的手术方案主要是峡部修补、椎管减压、滑脱复位、脊柱融合,治疗原则主要是缓解神经压迫、恢复脊柱稳定,但对于各环节实施的具体方式及程度仍存在较大争议。开放手术能够对严重峡部裂腰椎滑脱进行彻底的减压、复位、融合,重建脊柱的稳定性,但手术创伤过大,而微创手术则可以减少对椎旁软组织的损伤,同时减少术中失血量,缩短术后住院及康复时间,降低术中、术后相关并发症的发生率,因而近年来也受到了越来越多临床医生的推崇,但对于重度峡部裂腰椎滑脱的治疗效果欠佳。现就近年来腰椎滑脱的手术治疗进展做一综述。     

单节段微创经椎间孔腰椎椎体间融合内固定治疗腰椎滑脱症的效果

目的:评价单节段微创经椎间孔腰椎椎体间融合(minimally invasive transforaminal lumbar interbodyfusion,MiTLIF)内固定治疗腰椎滑脱症的临床效果。方法:2007年1月~2010年3月163例腰椎滑脱症患者接受单节段MiTLIF和内固定治疗。男61例,女102例;年龄37～72岁,平均51.6岁。退变性腰椎滑脱97例,峡部裂性腰椎滑脱66例;Ⅰ度滑脱135例,Ⅱ度28例;L3滑脱7例,L4 86例,L5 70例。采用经最长肌和多裂肌间隙入路,可扩张工作通道置于关节突上,行MiTLIF和经皮椎弓根螺钉固定。将163例患者按时间顺序依次分为A组(第1~55例)、B组(第56~110例)和C组(第111~163例),统计手术时间、术中X线暴露时间、术中和术后出血量及并发症发生情况,并进行组间比较。采用腰痛视觉模拟评分(VAS)和功能障碍指数(ODI)评分评估临床效果,腰椎薄层CT扫描重建评价椎间融合情况。结果:163例术中出血100～750ml,平均330ml;术后出血10～175ml,平均57ml;手术时间83～230min,平均145min;术中X线暴露时间27～126s,平均59s。B组术中出血量和X线暴露时间与A组比较及C组手术时间、X线暴露时间、术中和术后出血量与A组比较均明显减少(P<0.05);C组手术时间、术中X线暴露时间、术中和术后出血量与B组比较亦明显减少(P<0.05)。7例术中硬膜囊撕裂,其中A组4例,B组2例,C组1例,均在术后第2天出现脑脊液漏,经对症处理术后5d内脑脊液漏停止。4例术后出现新的神经根损害表现,均为A组病例,通过内窥镜下减压和神经根松解后神经根损害症状消失。91例患者获得10～47个月随访,平均24.5个月。术前、术后3d及末次随访腰痛VAS评分分别为6.8±2.4分、1.5±0.6分和0.8±0.4分,术后3d及末次随访与术前比较有显著性差异(P<0.05)。术前及末次随访ODI评分分别为39.4±5.1分和11.3±2.6分,差异有显著性(P<0.05)。末次随访椎间融合率为96.7%(88/91)。结论:采用单节段MiTLIF和经皮椎弓根螺钉固定治疗Ⅰ度、Ⅱ度腰椎滑脱症安全有效。     

Cost-effectiveness of open transforaminal lumbar interbody fusion (OTLIF) versus minimally invasive transforaminal lumbar interbody fusion (MITLIF): a systematic review and meta-analysis

Background ContextThe number of performed instrumented lumbar spine surgeries and associated health-care-related costs has increased over the last decades, and will increase further in the future. With the consistent growth of health-care-related costs, cost-effectiveness of surgical techniques is of major relevance. Common indications for instrumented lumbar spine surgery are spondylolisthesis and degenerative disease. A commonly used technique is the open transforaminal lumbar interbody fusion (OTLIF). Nowadays, there is an increasing interest in the minimally invasive variation of this technique (minimally invasive transforaminal lumbar interbody fusion [MITLIF]). Currently available literature describes that MITLIF has comparable or even better clinical results compared to OTLIF. Cost-effectiveness of MITLIF and OTLIF is important considering the growing health-care related costs, although no consensus has been reached regarding the most cost-effective technique. In this systematic review, previous literature concerning costs and cost-effectiveness of OTLIF was compared with MITLIF in patients with lumbar spondylolisthesis or degenerative disease. Furthermore, methodological quality of included studies was assessed.PurposeThis study aims to evaluate the current literature on cost-effectiveness of OTLIF compared MITLIF to in patients with lumbar spondylolisthesis or degenerative disease.Study DesignThis study is a systematic literature review and meta-analysis.Study SampleClinical studies reporting costs or cost-effectiveness for either OTLIF or MITLIF in patients with spondylolisthesis, lumbar instability, or degenerative disease were included.Outcome MeasuresThe following data items were evaluated: study design, study population, utility measurement tool, gained quality adjusted life years (QALYs), cost sources, health care and societal perspective costs, total costs, costs per QALY (cost-effectiveness) and incremental cost-effectiveness ratio (ICER).MethodsA systematic search was conducted using databases PubMed, CINAHL, EMBASE, Cochrane, Clinical Trials, Current Controlled Trials, ClinicalTrials.gov, NHS Centre for Review and Dissemination, Econlit and Web of Science on studies reporting OTLIF or MITLIF, spondylolisthesis or lumbar instability or degenerative disease, and costs. Relevant studies were selected and reviewed independently by two authors. For comparison, all costs were converted to American dollars with the reference year 2018.ResultsAfter duplicate removal, a total of 892 studies were identified. Eventually, 32 studies were included. Nine studies compared OTLIF and MITLIF directly. All studies mentioned health care perspective costs. Seven studies mentioned societal perspective costs. Cost-effectiveness of OTLIF was mentioned in five studies, ranging from $47,303/QALY to $218,766/QALY. Cost-effectiveness of MITLIF was mentioned in one study, $121,105/QALY. Meta-analysis of hospital perspective costs showed a significant overall effect in favor of MITLIF, with a mean difference of $2,650. There was great heterogeneity in health care and societal perspective costs due to different in-, and exclusion factors, baseline characteristics, and calculation methods. Overall quality of studies was low.ConclusionsOTLIF and MITLIF appear to be expensive interventions when using a threshold of $50,000/QALY. Results of this study and previous literature suggest that MITLIF is more cost-effective compared to OTLIF. Considering the increase in health care costs of instrumented spine surgery, cost-effectiveness could be one of the factors in surgical decision-making. Prospective randomized studies directly comparing cost-effectiveness of OTLIF and MITLIF from both hospital and societal perspectives are needed to obtain higher level of evidence.     

National trends in lumbar spine decompression and fusion surgery in Finland, 1997–2018

Background and purpose — During recent years, spine surgery techniques have advanced, the population has become older, and multiple high-quality randomized controlled trials that support surgical treatment for degenerative spinal stenosis and spondylolisthesis have been published. We assess the incidence and trends in spine fusion and decompression surgery in Finland between 1997 and 2018.Patients and methods — We used nationwide data from the Finnish nationwide National Hospital Discharge Register. The study population covered all patients aged 20 years or over in Finland (5.5 million inhabitants) during a 22-year period from 1997 through 2018. All patients who underwent spinal decompression were included. Patients with both decompression and fusion codes were analyzed as fusions.Results — 76,673 lumbar spine decompressions and fusions were performed during the study period. The incidence of lumbar spine decompressions increased from 33 (95% CI 23–45) per 100,000 person-years in 1997 to 77 (CI 61–95) per 100,000 person-years in 2018. The incidence of lumbar spine fusions increased from 9 (CI 5–17) per 100,000 person-years in 1997 to 30 (CI 21–43) per 100,000 person-years in 2018. The increase in incidence of lumbar spinal fusions was highest among women aged over 75 years, with a 4-fold increase.Interpretation — The incidence of lumbar spine fusions and decompressions increased between 1997 and 2018 in Finland. These findings may be the result of the emergence of advanced surgical techniques but may also be the result of an aging population and increased evidence supporting the surgical treatment of various spinal pathologies.

During recent years, there has been an increasing trend for the surgical treatment of degenerative spine pathologies (Gray et al. 2006). For example, more than 240 000 decompression procedures were performed in the United States in 2007. In 2004, the total cost of spine fusion and decompression surgeries in the United States was estimated to be 21 billion USD (Deyo 2007). Previous studies from the US have shown that the incidence of surgically treated degenerative spine pathologies slowly increased between 1980 and 1990 (Taylor et al. 1994). Thereafter, the rates rapidly increased from 1990 to 2010 (Deyo et al. 2005, Patil et al. 2005, Passias et al. 2017). According to a study by Seitsalo (1996), the incidence of lumbar spine fusion operations in Finland increased by 103% between 1987 and 1994. Conversely, they also reported that the incidence of lumbar spine decompression decreased by 12% during the same period. Recent trends in lumbar spine fusion and decompression surgery in Finland are not known, however.Spine surgery has undergone many evolutionary steps during the previous decades (Patil et al. 2005, Kim et al. 2011). Of these, new, less invasive techniques (Kim et al. 2011), better availability, higher quality of MRI (Patil et al. 2005), and a better understanding of degenerative spine pathologies (Patil et al. 2005, Passias et al. 2017) have all been presented as major factors behind the increasing incidence of spine surgery. Most importantly, multiple high-quality randomized controlled trials (RCT) supporting the operative treatment of degenerative spinal stenosis (Weinstein et al. 2008, 2010, Lurie et al. 2015) and spondylolisthesis (Weinstein et al. 2007, Ekman et al. 2009, Weinstein et al. 2009) have recently been published. By contrast, the effect of spinal fusion is debated (Försth et al. 2016).Taking into account the increasing trends in degenerative spine surgery and recent scientific evidence supporting surgery, we evaluated the changes in the incidence of spinal fusion and decompression surgery in Finland between 1997 and 2018.      

Treatment of degenerative spondylolisthesis

The purpose of this article is to evaluate three surgical approaches to the treatment of degenerative spondylolisthesis. A review of 107 surgically treated cases were used to select a group of patients who met the following criteria: No previous spine surgery, no involvement in litigation, and no significant lesions at other levels of the spine. Adequate follow-up. The selected group of 47 surgically treated cases of degenerative spondylolisthesis had follow-up of 2-7 years. Three surgical approaches to the treatment of degenerative spondylolisthesis were analyzed. A relatively small patient group with a wide posterior decompression, at the level of the slip, sacrificing the articular processes had good to excellent results in only 33% of the cases. A second group with a midline posterior decompression with preservation of the articular processes had 80% good to excellent results after 2 years. The third group with a midline decompression and preservation of the articular processes had an added intertransverse process fusion between the olisthetic levels. This group had 90% good to excellent results. The conclusion is that a posterior decompression with preservation of the articular processes plus a transverse process fusion at the involved level is the preferred method of treatment for degenerative spondylolisthesis without regard to age.     

Anterolisthesis and retrolisthesis of the cervical spine in cervical spondylotic myelopathy in the elderly

Background Degenerative spondylolisthesis of the cervical spine has received insufficient attention in contrast to that of the lumbar spine. The authors analyzed the functional significance of anterior and posterior degenerative spondylolisthesis (anterolisthesis and retrolisthesis) of the cervical spine to elucidate its role in the development of cervical spondylotic myelopathy (CSM) in the elderly. Methods A total of 79 patients aged 65 or older who eventually had surgical treatment for CSM were evaluated radiographically. Results Altogether, 24 patients (30%) had displacement of 3.5 mm or more (severe spondylolisthesis group), 31 had displacement of 2.0–3.4 mm (moderate spondylolisthesis group), and 24 had less than 2.0 mm displacement (mild spondylolisthesis group). The severe spondylolisthesis group consisted of 14 patients with anterolisthesis (anterolisthesis group) and 10 patients with retrolisthesis (retrolisthesis group). Patients with severe spondylolisthesis had a high incidence (93%) of degenerative spondylolisthesis at C3/4 or C4/5 and significantly greater cervical mobility than those with mild spondylolisthesis. The anterolisthesis group, but not the retrolisthesis group, had a significantly wider spinal canal than the mild spondylolisthesis group, although the degree of horizontal displacement and cervical mobility did not differ significantly between the anterolisthesis and retrolisthesis groups. Severe cord compression seen on T1-weighted magnetic resonance imaging (MRI) scans and high-intensity spinal cord signals seen on T2-weighted MRI scans corresponded significantly to the levels of the spondylolisthesis. Conclusions Degenerative spondylolisthesis is not a rare radiographic finding in elderly patients with CSM, which tends to cause intense cord compression that is seen on MRI scans. Greater mobility of the upper cervical segments may be a compensatory reaction for advanced disc degeneration of the lower cervical segments, leading to the development of degenerative spondylolisthesis. With a similar degree of displacement, anterolisthesis tends to have a greater impact on the development of CSM than retrolisthesis.     

Predictors of outcomes after posterior decompression and fusion in degenerative spondylolisthesis

No consensus has been reached regarding surgical management of degenerative spondylolisthesis. The optimal type of surgical procedure and surgical indications have not been precisely defined. In order to screen for predictors of outcome, we retrospectively studied patient outcomes after posterior decompression and fusion for isolated lumbar degenerative spondylolisthesis. Twenty-four consecutive patients (age range 50–78 years) underwent primary surgery for isolated lumbar degenerative spondylolisthesis. The surgical procedure consisted of posterior decompression and pedicle screw instrumented fusion using autogeneous bone graft, with or without interbody fusion. Clinical and radiologic status were assessed using the Beaujon functional score and plain AP and lateral radiographs. A multivariate analysis was used to correlate the functional score increase with surgical procedure modifications and preoperative clinical and radiologic features in order to determine which of them led to better results. Eighteen patients completed the evaluation. Six others were lost to follow-up after a minimum of 0.87 years. Combining all the results, the mean follow-up was 2.87 years. The Beaujon score was improved in the 24 patients (P<0.001), and fusion was successful in all cases. Additional interbody fusion and preoperative leg pain were significantly correlated with larger score increase (P=0.016 and P=0.003). Posterior decompression and fusion is successful in treating lumbar degenerative spondylolisthesis. From this study, circumferential fusion improves the outcomes and leg pain is a fair indication for surgery.     

Surgical treatment for spondylolisthesis in the adult.

There are 3 common types of spondylolisthesis: dysplastic; isthmic; degenerative. This classification, presented anew in an article published in this volume, evolved from a discussion by the members of the International Society for the Study of the Lumbar spine. The surgical treatment is designed to correct a combination of symptomatic and mechanical abnormalities characteristic of each type.     

Radiographic evaluation of posterolateral lumbar fusion for degenerative spondylolisthesis: long-term follow-up of more than 10 years vs. midterm follow-up of 2–5 years

Although posterolateral fusion of the lumbar spine without instrumentation has been widely performed for spinal instability caused by degenerative spondylolisthesis in the lumbar spine, few long-term follow-up studies have been reported. We studied ten patients who underwent posterolateral fusion for degenerative spondylolisthesis in the lumbar spine without instrumentation in our hospital, five of whom were followed up for more than 10 years and the other five for 2–5 years. We used radiography to examine their fusion status, instability and degenerative changes at the fusion level, change in the slip, change in lumbar lordosis, and instability and degenerative changes one level above and one level below the fusion. In most of the ten patients, radiographic evaluation demonstrated solid fusion, minimal degenerative changes, and preservation of lumbar lordosis and spinal mobility. Posterolateral lumbar fusion for degenerative spondylolisthesis in the lumbar spine seems promising for obtaining not only good radiographic features but also good clinical results lasting over more than 10 years. Electronic Publication     

High failure rate of the interspinous distraction device (X-Stop) for the treatment of lumbar spinal stenosis caused by degenerative spondylolisthesis

The X-Stop interspinous distraction device has shown to be an attractive alternative to conventional surgical procedures in the treatment of symptomatic degenerative lumbar spinal stenosis. However, the effectiveness of the X-Stop in symptomatic degenerative lumbar spinal stenosis caused by degenerative spondylolisthesis is not known. A cohort of 12 consecutive patients with symptomatic lumbar spinal stenosis caused by degenerative spondylolisthesis were treated with the X-Stop interspinous distraction device. All patients had low back pain, neurogenic claudication and radiculopathy. Pre-operative radiographs revealed an average slip of 19.6%. MRI of the lumbosacral spine showed a severe stenosis. In ten patients, the X-Stop was placed at the L4–5 level, whereas two patients were treated at both, L3–4 and L4–5 level. The mean follow-up was 30.3 months. In eight patients a complete relief of symptoms was observed post-operatively, whereas the remaining 4 patients experienced no relief of symptoms. Recurrence of pain, neurogenic claudication, and worsening of neurological symptoms was observed in three patients within 24 months. Post-operative radiographs and MRI did not show any changes in the percentage of slip or spinal dimensions. Finally, secondary surgical treatment by decompression with posterolateral fusion was performed in seven patients (58%) within 24 months. In conclusion, the X-Stop interspinous distraction device showed an extremely high failure rate, defined as surgical re-intervention, after short term follow-up in patients with spinal stenosis caused by degenerative spondylolisthesis. We do not recommend the X-Stop for the treatment of spinal stenosis complicating degenerative spondylolisthesis.     

Degenerative spondylolisthesis of the cervical spine: analysis of 58 patients treated with anterior cervical decompression and fusion

Background contextDegenerative spondylolisthesis has been well described as a disorder of the lumbar spine. Few authors have suggested that a similar disorder occurs in the cervical spine. To our knowledge, the present study represents the largest series of patients with long-term follow-up who were managed surgically for the treatment of degenerative spondylolisthesis of the cervical spine.PurposeTo describe the clinical presentation and radiographic findings associated with degenerative cervical spondylolisthesis, and to report the long-term results of surgically managed patients.Study designAnalysis of 58 patients treated with anterior cervical decompression and fusion for degenerative spondylolisthesis of the cervical spine.Patient sampleFrom 1974 to 2003, 58 patients were identified as having degenerative spondylolisthesis of the cervical spine occurring in the absence of trauma, systemic inflammatory arthropathy, or congenital abnormality. These patients were identified from a database of approximately 500 patients with degenerative cervical spine disorders treated by the senior one of us.Outcome measuresPatient outcomes were evaluated with regard to neurologic improvement (Nurick grade myelopathy) and osseous fusion.MethodsThe records of 58 patients were reviewed. The average follow-up period was 6.9 years (range, 2–24 years). Seventy-two cervical levels demonstrated spondylolisthesis. In all cases, there was radiographic evidence of facet degeneration and subluxation. All patients were treated with anterior cervical decompression and arthrodesis with iliac crest structural graft. This most commonly involved corpectomy of the caudal vertebrae. Three patients required additional posterior facet fusion.ResultsFifty-eight patients demonstrated 72 levels of involvement. The C4–C5 level was most frequently involved (43%). Two radiographically distinct types of listhesis were observed based on the amount of disc degeneration and the degree of spondylosis at adjacent levels. The average neurologic improvement was 1.5 Nurick grades. The overall fusion rate was 92%. Three patients were treated with combined anterior-posterior arthrodesis. The prevalence of myelopathy and instability pattern was greater in the listheses occurring adjacent to spondylotic levels.ConclusionsDegenerative spondylolisthesis is relatively common in the cervical spine. Common to all cases is facet arthropathy and neurologic compression. Anterior cervical decompression and arthrodesis appears to yield excellent union rates and neurological improvement in those patients having cervical degenerative spondylolisthesis and significant neurological sequelae who have failed nonoperative treatments.     

Spondylolisthesis and related disorders. A correlative study of 105 patients

A close relation exists among the alterations in the lumbosacral spine designated as spondylolysis, isthmic spondylolisthesis, degenerative spondylolisthesis, and prespondylolisthesis. While the former two conditions are probably caused by faulty development and subsequent minor traumata or repeated stresses, the third condition is caused by degenerative changes associated with anatomic variations; the fourth condition is a static insufficiency leading to faulty alignment. In 105 patients, the initial preferred management of these conditions was conservative. Thirty-four patients who developed persistent symptoms of spinal instability and/or intractable neurologic deficits were treated surgically. The results were generally successful.     

Radiographic evaluation of posterolateral lumbar fusion for degenerative spondylolisthesis: long-term follow-up of more than 10 years vs. midterm follow-up of 2-5 years.

Although posterolateral fusion of the lumbar spine without instrumentation has been widely performed for spinal instability caused by degenerative spondylolisthesis in the lumbar spine, few long-term follow-up studies have been reported. We studied ten patients who underwent posterolateral fusion for degenerative spondylolisthesis in the lumbar spine without instrumentation in our hospital, five of whom were followed up for more than 10 years and the other five for 2-5 years. We used radiography to examine their fusion status, instability and degenerative changes at the fusion level, change in the slip, change in lumbar lordosis, and instability and degenerative changes one level above and one level below the fusion. In most of the ten patients, radiographic evaluation demonstrated solid fusion, minimal degenerative changes, and preservation of lumbar lordosis and spinal mobility. Posterolateral lumbar fusion for degenerative spondylolisthesis in the lumbar spine seems promising for obtaining not only good radiographic features but also good clinical results lasting over more than 10 years.     

High Grade Infective Spondylolisthesis of Cervical Spine Secondary to Tuberculosis

Spondylolisthesis coexisting with tuberculosis is rarely reported. There is a controversy whether spondylolisthesis coexists or precedes tuberculosis. Few cases of pathological spondylolisthesis secondary to tuberculous spondylodiscitis have been reported in the lumbar and lumbosacral spine. All cases in the literature presented as anterolisthesis, except one which presented as posterolisthesis of lumbar spine. Spondylolisthesis in the cervical spine is mainly degenerative and traumatic. Spondylolisthesis due to tuberculosis is not reported in the lower cervical spine. The exact mechanism of such an occurrence of spondylolisthesis with tuberculosis is sparsely reported in the literature and inadequately understood. We report a rare case of high grade pathological posterolisthesis of the lower cervical spine due to tubercular spondylodiscitis in a 67-year-old woman managed surgically with a three-year follow-up period. This case highlights the varied and complex presentation of tuberculosis of the lower cervical spine and gives insight into its pathogenesis, diagnosis, and management.     

退变性腰椎滑脱患者多裂肌萎缩与滑脱程度相关性研究

目的分析退变性腰椎滑脱症患者滑脱节段多裂肌萎缩程度与腰椎滑脱程度的相关性。方法回顾分析2008年1月至2019年4月本院就诊的103例腰椎退变性滑脱症的患者资料,其中男22例,女81例;年龄(58.55±0.88)岁(范围:37~77岁)。L2滑脱2例,L3滑脱10例,L4滑脱81例,L5滑脱10例。所有患者均摄腰椎侧位X线片,行腰椎MR检查。收集影像学资料,采用Image-Pro Plus进行数据测量:①腰椎侧位X线片上测量腰椎滑脱比;②腰椎MR上分别测量退变性滑脱节段的总多裂肌横截面积(total multifidus muscle cross sectional area,TCSA)与无脂肪浸润多裂肌横截面积(fat-free multifidus muscle cross sectional area,FCSA),并计算FCSA/TCSA比值,用来评估多裂肌萎缩程度,该数值越大表明多裂肌萎缩越轻;采用同样的方法测量退变性滑脱节段的上一非滑脱节段的TCSA与FCSA,并计算FCSA/TCSA比值。结果对两位医生的测量结果进行一致性检验,腰椎滑脱比数据进行一致性检验,ICC=>0.75,说明数据一致性高,结果可信度高。退变滑脱节段上一非滑脱节段和退变滑脱节段的多裂肌萎缩程度(FCSA/TCSA比值)分别为0.66±0.09和0.74±0.08,差异有统计学意义(t=-12.618,P=0.000);103例中Ⅰ度滑脱66例(64.1%,66/103),Ⅱ度滑脱患者37例(35.9%,37/103),无Ⅲ度及Ⅳ度滑脱患者;滑脱比与退变滑脱节段FCSA/TCSA存在相关性(P=0.000),相关系数γ=-0.425,滑脱比与退变节段FCSA/TCSA存在高度负相关。结论退变性腰椎滑脱症患者退变滑脱节段多裂肌萎缩程度较退变滑脱节段上一非滑脱节段多裂肌萎缩程度严重;退变性腰椎滑脱症患者退变滑脱节段多裂肌萎缩程度与腰椎滑脱程度存在正相关。     

Rotational instability of the lumbar spine--a three-dimensional motion study using bi-plane X-ray analysis system

The purpose of this study is to investigate the rotational instability of the lumbar spine using bi-plane X-ray analysis system and to clarify mechanical etiology of the lumbar instability. The following results were obtained. (1) The range of rotational motion was about 2 to 3 degrees at each motion segment in the normal lumbar spine. The rotational motion was significantly large in spondylolysis, spondylolisthesis, and degenerative spondylolisthesis. (2) The rotational instability and the flexion-extension instability correlated to each other in spondylolysis and spondylolisthesis. However, in degenerative spondylolisthesis, the rotational instability and the antero-posterior instability were correlated to each other. (3) Instantaneous axis of rotation (IAR) was located at the posterior part of the intervertebral disc in the normal L4 vertebra, and more posteriorly in the L5 vertebra, while the IAR was located anteriorly in spondylolysis, and posteriorly in degenerative spondylolisthesis. (4) When the trunk was twisted, the lumbar lordotic angle was generally decreased, and the lumbar spine showed scoliotic curvature convex to the twisted direction. The apex was located at the L4/5 intervertebral level. Highly significant increases in flexion motion associated with rotation were observed at the pathological levels of spondylolysis and degenerative spondylolisthesis.     

Management of spondylolisthesis using MIS techniques: Recent advances

The authors discuss the recent advances in the understanding and management of spondylolisthesis. The two most common kinds of spondylolisthesis - Degenerative and Spondylolytic types have been elaborated in this paper, with the understanding that similar management principles can be applied to the other lesser common varieties. The impetus has been on application of minimally invasive techniques in the treatment as well as renewed interest in stand-alone decompression in degenerative spondylolisthesis.     

Age-related changes in axial and sagittal orientation of the facet joints: Comparison with changes in degenerative spondylolisthesis

Background

Despite facet joints being three-dimensional structures, previous computed tomography and magnetic resonance imaging studies have evaluated facet joint orientation in only the axial plane. Facet joint orientation in the sagittal plane has rarely been studied using these imaging techniques. The aim of this study was to elucidate facet joint orientation in both the axial and sagittal planes on computed tomography.

Reoperations after decompression with or without fusion for L4–5 spinal stenosis with or without degenerative spondylolisthesis: a study of 6,532 patients in Swespine,the national Swedish spine register

Background and purpose — There are different opinions on how to surgically address lumbar spinal stenosis with concomitant degenerative spondylolisthesis (DS). We investigated reoperation rates at the index and adjacent levels after L4–5 fusion surgery in a large cohort of unselected patients registered in Swespine, the national Swedish spine register.Patients and methods — 6,532 patients, who underwent surgery for L4–5 spinal stenosis with or without DS between 2007 and 2012, were followed up to 2017 to identify reoperations at the index and adjacent levels. The reoperation rates for decompression and fusion were compared with the reoperation rates for decompression only and for patients with or without DS. Patient-reported outcome data were collected preoperatively, and at 1 and 2 years after surgery and used to evaluate differences in outcome between index operations and reoperations.Results — For spinal stenosis with DS, the reoperation rate at the index level was 3.0% for decompression and fusion and 6.0% for decompression only. At the adjacent level, the corresponding numbers were 9.7% and 4.2% respectively. For spinal stenosis without DS, the reoperation rate at the index level was 3.7% for decompression and fusion and 6.2% after decompression only. At the adjacent level, the corresponding numbers were 8.1% and 3.8% respectively. For the reoperations at the adjacent level, there was no difference in patient-reported outcome between extended fusion or decompression only.Interpretation — Single-level lumbar fusion surgery is associated with an increased rate of reoperations at the adjacent level compared with decompression only. When reoperations at the index level are included there is no difference in reoperation rates between fusion and decompression only.

There is an ongoing controversy on how to surgically address lumbar spinal stenosis with and without concomitant degenerative spondylolisthesis (DS). The debate has focused on the durability of the index operation versus accelerated symptomatic degeneration at the adjacent segments. In this debate, durability has been defined as maintenance of clinical benefit without the need for additional intervention (Ghogawala et al. 2017). While decompression without fusion may increase the risk for early index-level reoperations for instability (Ghogawala et al. 2016, Urakawa et al. 2020), fusion surgery might increase the risk of adjacent segment disease (ASD) (Sears et al. 2011, Okuda et al. 2018).The national Swedish spine register (Swespine) covers 90% of the spine units in Sweden and the follow-up rate is 75–80% (Strömqvist et al. 2013). The Swespine offers possibilities to examine outcome in a large dataset of patients operated on for isolated L4–5 disease, which is the most common clinical scenario within spine surgery. Large register studies may contribute to increased evidence in this area.Using Swespine data, we investigated reoperation rates at the index and the adjacent levels after L4–5 decompression only or decompression and fusion for spinal stenosis with and without concomitant DS.     

Cervical Spine Surgery: An Historical Perspective

Background

Continued innovation in surgery requires a knowledge and understanding of historical advances with a recognition of successes and failures.

Questions/purposes

To identify these successes and failures, we selectively reviewed historical literature on cervical spine surgery with respect to the development of (1) surgical approaches, (2) management of degenerative disc disease, and (3) methods to treat segmental instability.

Methods

We performed a nonsystematic review using the keywords “cervical spine surgery” and “history” and “instrumentation” and “fusion” in combination with “anterior approach” and “posterior approach,” with no limit regarding the year of publication. Used databases were PubMed and Google Scholar. In addition, the search was extended by screening the reference list of all articles.

Results

Innovative surgical approaches allowed direct access to symptomatic areas of the cervical spine. Over the years, we observed a trend from posterior to anterior surgical techniques. Management of the degenerative spine has evolved from decompressive surgery alone to the direct removal of the cause of neural impingement. Internal fixation of actual or potential spinal instability and the associated instrumentation have continuously evolved to allow more reliable fusion. More recently, surgeons have developed the basis for nonfusion surgical techniques and implants.

Conclusions

The most important advances appear to be (1) recognition of the need to directly address the causes of symptoms, (2) proper decompression of neural structures, and (3) more reliable fusion of unstable symptomatic segments.