Endoscopic laser foraminoplasty and a aware-state surgery: a treatment concept and 2-year outcome analysis

Aware-state surgery has been used in this unit to identify the source of spinal pain in over 2500 patients as part of a process termed “viviprudence”. This process consists of clinical analysis, dynamic radiology and scanning tested by differential discography, endoscopy and patient feedback. This replaces guesswork with sighted diagnosis and allows keyhole tissue-preserving techniques to be used not only for the treatment of compressive radiculopathy but also for back pain, failed back syndrome, perineural scarring, multilevel degenerative disc disease, lateral recess stenosis and dynamic listhesis. This has led to the identification of new pathology and the refinement of the inclusion criteria for laser disc decompression and endoscopic laser foraminoplasty. Since 1994, an endoscopic system has been developed to explore the intervertebral foramen and epidural space via the postero-lateral route. The system has been used to address lateral recess stenosis, epidural scarring, osteophytosis, settlement, listhesis, disc extrusion and sequestration and failed back syndrome. The objective has been the endoscopic aware-state definition of the source of pain with decompression of the foramen, mobilisation and neurolysis of the exiting and transiting nerves and ablation of osteophytes and other causes of failed back syndrome confirmed endoscopically. This prospective study involved day-case endoscopic laser foraminoplasty performed on 101 men, and 99 women with an average age of 56 years (range, 22–83 years). They were followed for an average period of 34 months (range, 26–43 months). The average preoperative duration of symptoms was 5.6 years (range, 5–11 years). A total of 46 patients had had one to four previous open operations, and 14 patients were on narcotic analgesics prior to surgery. At other centres, 106 of these patients were evaluated and open surgical procedures were not deemed appropriate or likely to benefit. A cohort integrity of 96% was maintained at the final follow-up. Back, buttock and leg pain were separately compared and analysed using the Oswestry Disability Index, a patient satisfaction scoring scale, a visual analogue pain scale and a patient target achievement score. Using an Oswestry Disability Index of 50 or more to determine good and excellent outcomes, 55% of patients exceeded this score for back pain, 52% for buttock pain and 53% for leg pain. In patients with one prior operation, the corresponding figures were 51%, 33% and 29%. These results indicate that endoscopic laser foraminoplasty provides a minimalist means of exploring the extraforaminal zone, the foramen and the epidural space and performing discectomy, osteophytectomy and neurolysis. It incorporates the prophylactic advantage of foraminal undercutting and provides a promising means of identifying and treating the pain of failed back surgery and back pain and sciatica of indeterminate origin. It serves to identify and localise the source of pain generation. Endoscopic laser foraminoplasty avoids the morbidity associated with open spinal surgery and serves as a useful means of effecting keyhole neurolysis without extensive exploration and fusion. Current improvements in equipment promise wider application and more encouraging results in the future.      

Preoperative retrolisthesis as a predictive risk factor of reoperation due to delayed-onset symptomatic foraminal stenosis after central decompression for lumbar canal stenosis without fusion

Background Context

For patients diagnosed with lumbar central canal stenosis with asymptomatic foraminal stenosis (FS), surgeons occasionally only decompress central stenosis and preserve asymptomatic FS. These surgeries have the potential risk of converting preoperative asymptomatic FS into symptomatic FS postoperatively by accelerating spinal degeneration, which requires reoperation. However, little is known about delayed-onset symptomatic FS postoperatively.

A slip above a slip: retrolisthesis of the motion segment above a spondylolytic spondylolisthesis

Objective

The purpose of this study is to assess the degenerative changes in the motion segments above a L5S1 spondylolytic spondylolisthesis and to view these in light of the retrolisthesis in the segment immediately above the slip.

Background summary

A spondylolytic spondylolisthesis causes an abnormal motion and predisposes to degenerative changes at the L5S1 disc. Degenerative changes in the adjacent segments would influence the symptomatology and natural history of the disease and the treatment options. The extent of degenerative changes in the levels immediately above a L5S1 spondylolytic spondylolisthesis is not well documented in the literature. We have noted retrolisthesis at this level, but this has not been previously reported or assessed.

Materials and methods

Thirty-eight patients with a symptomatic L5S1 spondylolytic spondylolisthesis with a mean age of 52.8 years (95% CI 47.2–58.4); 55.3% (n = 21) females and 44.7% (n = 17) males. We assessed the lumbar lordosis, slip angle, sacral slope, grade of the slip, facet angles at L34 and L45 on both sides, facet degenerative score (cartilage and sclerosis values), disc degenerative score (Pfirrmann) at L34, L45 and L5S1 and the presence of retrolisthesis at L45.

Results

We noted that 29% (11) had a retrolisthesis at L45. The degenerative scores reduced significantly from L5S1 through L45 and L34. Slip angle and L45 disc degenerative score were the only factors that occurred consistently in patients with a retrolisthesis.

Conclusions

There is a cascade of degenerative changes that involve both the disc and the facet joints at the levels above a spondylolytic spondylolisthesis. The degenerative changes at the L45 disc and a higher slip angle are consistent findings in patients with a retrolisthesis at the level above the slip.     

The radiographic distinction of degenerative slippage (spondylolisthesis and retrolisthesis) from traumatic slippage of the cervical spine

In a review of 42 cases of degenerative arthritis of the cervical spine and 22 cases of cervical spine trauma with an observed anterior slippage (spondylolisthesis) or posterior slippage (retrolisthesis) of the vertebral bodies of 2 mm or more, characteristic features were observed which allowed distinction between degenerative and traumatic slippage of the cervical spine. In degenerative slippage the shape of the articular facets and width of the facet joint space may remain normal; however, in most cases the articular facets become ground-down with narrowing of the facet joint space and the articular facets themselves becoming thinned or ribbon-like. In traumatic slippage the artucular facets will either be normally shaped or fractured and the facet joint space will be abnormally widened. Plain radiographs will usually allow this distinction to be made; however, in difficult cases polytomography may be required.     

Retrolisthesis as a Compensatory Mechanism in Degenerative Lumbar Spine

ObjectivePosterior vertebral translation as a type of spondylolisthesis, retrolisthesis is observed commonly in patients with degenerative spinal problems. Nevertheless, there is insufficient literature on retrolisthesis compared to anterolisthesis. The purpose of this study is to clarify the clinical features of retrolisthesis, and its developmental mechanism associated with a compensatory role in sagittal imbalance of the lumbar spine.MethodsFrom 2003 to 2012, 230 Korean patients who underwent spinal surgery in our department under the impression of degenerative lumbar spinal disease were enrolled. All participants were divided into four groups : 35 patients with retrolisthesis (group R), 32 patients with simultaneous retrolisthesis and anterolisthesis (group R+A), 76 patients with anterolisthesis (group A), and 87 patients with non-translation (group N). The clinical features and the sagittal parameters related to retrolisthesis were retrospectively analyzed based on the patients'' medical records.ResultsThere were different clinical features and developmental mechanisms between retrolisthesis and anterolisthesis. The location of retrolisthesis was affected by the presence of simultaneous anterolisthesis, even though it predominantly manifest in L3. The relative lower pelvic incidence, pelvic tilt, and lumbar lordosis compared to anterolisthesis were related to the generation of retrolisthesis, with the opposite observations of patients with anterolisthesis.ConclusionRetrolisthesis acts as a compensatory mechanism for moving the gravity axis posteriorly for sagittal imbalance in the lumbar spine under low pelvic incidence and insufficient intra-spinal compensation.     

Lenke 5型青少年特发性脊柱侧凸患者前路选择性融合术后腰椎后滑脱的发生率及危险因素分析

【摘要】 目的：分析Lenke 5型青少年特发性脊柱侧凸（AIS）患者行前路选择性融合术后腰椎后向滑脱的发生率及其危险因素。方法：回顾性分析2005年1月～2010年12月在我院接受前路选择性胸腰椎融合手术的49例Lenke 5型AIS患者的临床资料。在术前、术后3个月及末次随访时的站立位全脊柱正侧位X线片上测量胸腰弯Cobb角、胸弯Cobb角、腰椎前凸角（lumbar lordosis,LL）、胸椎后凸角（thoracic kyphosis,TK）、胸腰段后凸角（thoracolumbar junctional kyphosis,TJK）、骶骨倾斜角（sacral slope,SS）、骨盆倾斜角（pelvic tilt,PT）、骨盆入射角（pelvic incidence,PI）、C7矢状位垂直距离（C7 sagittal vertical axis,SVA）。统计患者性别、年龄、Risser征、随访时间、融合椎体数、下端固定椎位置。按照Roussouly分型对患者术前矢状面形态进行分型。根据末次随访时发生腰椎后滑脱与否将患者分为滑脱组与非滑脱组。对两组患者术前、术后3个月及末次随访时的各参数进行统计学分析与比较。末次随访时采用脊柱侧凸研究会（SRS）-22量表评估两组患者生活质量。对有统计学差异的参数进行Logistic回归分析。结果：末次随访时24例（48.9%）患者发生后滑脱（滑脱组）,25例未发生后滑脱（非滑脱组）。两组患者性别、年龄、Risser征、矢状面Roussouly分型分布、融合节段、下端固定椎位置均无统计学差异（P>0.05）。滑脱组与非滑脱组患者随访时间为81.5±16.8个月与78.7±12.3个月。滑脱组患者术前、术后3个月及末次随访时的LL均显著性高于非滑脱组（P<0.039）,SVA均显著性低于非滑脱组（P<0.038）。术前及末次随访时,滑脱组TK显著性高于非滑脱组（P<0.041）。末次随访时,滑脱组SS显著性高于非滑脱组（P=0.036）。两组患者末次随访时SRS-22量表疼痛、功能等各项评分均无统计学差异（P>0.05）。Logistic回归分析显示SVA[比值比（odds ratio,OR）＝0.959,95%可信区间（confidence interval,CI） 0.925～0.994,P=0.024]与TK（OR＝1.158,95%CI 1.003～1.337,P=0.045）为术后后滑脱发生的危险因素。结论： Lenke 5型AIS患者接受前路选择性融合术后融合节段远端邻近节段发生后滑脱比例较高;术前较小的SVA与较大的TK为术后后滑脱发生的危险因素,而术前矢状面Roussouly分型与后滑脱发生无明显相关性;滑脱对腰椎椎间盘退变以及患者生活质量的影响仍需要远期随访评估。