Careful follow-up after "successful" surgery: postoperative spondylolisthesis after anterior cervical corpectomy and fusion with instrumentation

BACKGROUND: Anterior cervical corpectomy and fusion with instrumentation is a common procedure for the surgical treatment of cervical spinal cord and/or nerve root decompression or for deformity correction. However, various postoperative complications have been associated with such a surgical intervention. Postoperative spondylolisthesis after an anterior cervical corpectomy with instrumentation is a serious complication that has rarely been addressed in the literature, and may potentially be underreported. CASE DESCRIPTION: A 44-year-old woman with degenerative disk disease, loss of cervical lordosis, congenital cervical stenosis at C5-C6, and a left-sided herniated disk at C6-C7 underwent an anterior cervical corpectomy of C6 with fusion and anterior plate stabilization of C5-C7. Early postoperative evaluation noted complete resolution of the patient's symptoms. At 6 months after surgery, the patient complained of neck pain and intermittent headaches. Radiographic evaluation noted fusion of the corpectomy strut graft with retrolisthesis of C5 on C6 and early myelomalacia at C5-C6. A cervical laminectomy with posterior instrumentation from C5 to C7 was performed and the patient's symptoms resolved. CONCLUSIONS: Postoperatively, a high index of suspicion should be present for the development of spondylolisthesis in patients undergoing an anterior cervical corpectomy and fusion procedure with or without instrumentation, particularly in individuals with persistent or new symptoms even after a "successful" operative procedure. The spine surgeon should address appropriate operative techniques and postoperative management to decrease the risk of spondylolisthesis after such a procedure.     

Circumferential fusion for the management of acute cervical spine trauma.

Combined, single-stage anterior and posterior approaches for acute surgical management of cervical spine injury allows for early restoration of anatomic alignment and decompression. Six patients underwent single-stage anterior decompression and posterior instrumentation and fusion at Vanderbilt University Medical Center between 1984-1989. There was no late deformity. Five patients had incomplete neurologic deficits, and each improved a minimum of one Frankel classification. One patient had complete neurologic deficit at the C5 level. The procedure is lengthy, with an average time under anesthesia of 7.7 hs. Since this procedure allows for immediate mobilization, it should be considered for the management of cervical spine fractures with both anterior and posterior column instability.     

Delayed postoperative paralysis in adolescent idiopathic scoliosis: management with partial removal of hardware and staged correction

A delayed spinal epidural hematoma following scoliosis surgery is relatively uncommon but well recognized by clinical and radiographic findings. A 12-year-old girl with scoliosis measuring 80 degrees lower thoracic curve underwent anterior (T6-T12) and posterior fusion with posterior instrumentation from T2 to L1. She developed bilateral leg weakness and progressive left lower leg paralysis 24 hours later. Emergent decompression and partial removal of hardware was performed. Reinsertion of segmental instrumentation and correction of her curve was performed 2 weeks later. The patient had complete recovery of her neurologic deficits, and her correction was maintained at 85% at 4-months follow-up. The authors recognized that there should be no delay in returning the patient to surgery if neurological deficits are noticed. Exploration and decompression of "an occupying lesion" and release of cord tension by partial removal of hardware and re-instrument can achieve appropriate original correction of scoliosis and satisfactory clinical outcome.     

Surgical treatment of cervical destructive spondyloarthropathy (DSA)

STUDY DESIGN: Sixteen patients with hemodialysis-associated cervical spine disorders underwent surgical treatment. After analysis of the surgical results, the optimum surgical procedures for these disorders were discussed. OBJECTIVE: To evaluate the surgical results of cervical spine disorders associated with long-term hemodialysis and to propose the optimum surgical procedures for successful outcomes. SUMMARY OF BACKGROUND DATA: There have been few reports regarding surgical results of hemodialysis-related cervical spine disorders. Surgical treatment for this disorder is still challenging. METHODS: Sixteen patients with hemodialysis-associated cervical spine disorders were treated surgically. Duration of hemodialysis ranged from 8 to 27 years (average, 17 years). Before surgery, 14 patients showed severe cervical myelopathy, and the other 2 had radiculopathy in the upper extremities. Ten patients with marked destructive changes underwent circumferential reconstructive surgery involving pedicle screw fixation, anterior strut bone grafting, and posterior and/or anterior decompression. Two patients with cervical radiculopathy underwent posterior nerve root decompression by foraminotomy and fusion by pedicle screw fixation or spinous process wiring. The remaining four patients without spinal instability underwent posterior decompression by open-door laminoplasty. RESULTS: Two patients died during follow-up. Follow-up periods in the surviving 14 patients ranged from 25 months to 92 months (average, 53 months). Marked neurologic recovery was obtained in all patients after surgery. Successful spinal fusion was obtained in all patients except one who underwent posterior fusion by spinous process wiring. Progressive destructive changes with significant instability at the adjacent mobile segments were observed in two patients who underwent circumferential fusion with a pedicle screw system more than 2 years after the initial surgery. CONCLUSIONS: The pedicle screw system achieved a high fusion rate in reconstructive surgery of cervical destructive spondyloarthropathy, even in the presence of severe bone fragility.     

The results of simultaneous posterior–anterior–posterior surgery in multilevel tuberculosis spondylitis associated with severe kyphosis

We retrospectively studied the cases with tuberculous spondylitis of thoracolumbar region with two or more levels of involvement that underwent posterior instrumentation and fusion and anterior fusion with titanium mesh following anterior decompression using simultaneous successive posterior–anterior–posterior surgery. Among all patients with tuberculous spondylitis accompanied by medium or severe kyphosis, 20 patients who underwent simultaneous successive decompression, fusion and instrumentation with posterior–anterior–posterior surgery between 1999 and 2004 were included in the study. Patients were evaluated for fusion formation and neurological and functional status. Kyphosis angles were measured at early and long-term follow-up. Antituberculosis chemotherapy was initiated in all patients and continued for 9 months; initially as quadruple therapy for 3 months, and then as triple therapy. Average follow-up period was 52.7 months (range 37–94). Solid fusion was achieved in all patients. All patients returned to their previous occupation; 75% (15 subjects) with mild pain or no pain and 15% (3 subjects) with major limitations. There were 11 patients with neurological deficit, 9 of these achieved complete neurological recoveries. Regarding kyphosis angle, an average 35.1° correction (84.8%) was obtained in postoperative period (p < 0.001) and there was no significant correction loss during the follow-up period (p < 0.05). There were no grafts or instrumentation-related stabilization problems. In subjects with tuberculous spondylitis with involvements at two or more levels accompanied by medium and severe kyphosis, decompression, fusion and instrumentation by simultaneous successive posterior–anterior–posterior surgery is an effective and safe management method for effective kyphosis correction with high fusion rates.     

Surgery for severe spondylolisthesis and spondyloptosis

Objective  Restoration of a normal profile of spinal column by complete or almost complete reduction, stabilization achieved by instrumentation and fusion of the lumbosacral intervertebral segment. Alleviation or at least marked reduction of pain and neurologic deficits present before surgery. Indications  High grade, that means usually spondylolisthesis grade IV according to Meyerding or spondyloptosis. Patients with progression of slip. Contraindications  Osteopenia. Spondylolistheses which do not necessitate an opening of the spinal canal. Possibility of adequate anterior access to the lumbosacral disk. Surgical Technique  Posterior decompression and resection of the sacral dome, reduction of L5 over the sacrum and posterior interbody fusion L5/S1 with two autogenous bi- or tricortical bone grafts harvested from the iliac crest. Results  Between January 1995 and January 1998, we used the described technique in eleven patients. Six patients had a grade IV spondylolisthesis and five a spondyloptosis. Previous surgery had been done in four patients. A complete or almost complete reduction was possible in ten patients. No pseudarthrosis nor loss of correction were seen. Neurologic deficits improved in five of six patients. All patients noted an improvement of symptoms. Postoperative complications in previously operated patients: one dura lesion, one deficit of the S1 nerve root diagnosed postoperatively, and one inadequate reduction. Postoperative complications in the remaining seven, not previously operated patients: one instability of the adjacent segment and a transient irritation of the L5 nerve root in two patients.     

One-stage posterior instrumentation surgery for the treatment of osteoporotic vertebral collapse with neurological deficits

The number of reports describing osteoporotic vertebral fracture has increased as the number of elderly people has grown. Anterior decompression and fusion alone for the treatment of vertebral collapse is not easy for patients with comorbid medical problems and severe bone fragility. The purpose of the present study was to evaluate the efficacy of one-stage posterior instrumentation surgery for the treatment of osteoporotic vertebral collapse with neurological deficits. A consecutive series of 21 patients who sustained osteoporotic vertebral collapse with neurological deficits were managed with posterior decompression and short-segmental pedicle screw instrumentation augmented with ultra-high molecular weight polyethylene (UHMWP) cables with or without vertebroplasty using calcium phosphate cement. The mean follow-up was 42 months. All patients showed neurologic recovery. Segmental kyphotic angle at the instrumented level was significantly improved from an average preoperative kyphosis of 22.8–14.7 at a final follow-up. Spinal canal occupation was significantly reduced from an average before surgery of 40.4–19.1% at the final follow-up. Two patients experienced loosening of pedicle screws and three patients developed subsequent vertebral compression fractures within adjacent segments. However, these patients were effectively treated in a conservative fashion without any additional surgery. Our results indicated that one-stage posterior instrumentation surgery augmented with UHMWP cables could provide significant neurological improvement in the treatment of osteoporotic vertebral collapse.     

Surgical treatment of post-traumatic kyphosis: a report of 16 cases

Thoracic and lumbar spine fractures may lead to symptomatic progressive kyphosis for which surgery remains a controversial treatment. Sixteen patients with kyphosis were treated surgically at the Sacré-Coeur Hospital in Montreal between 1979 and 1985. The mean follow-up was 38 months. Initially, treatment of the fractures varied. On average the post-traumatic kyphosis was surgically corrected 34 months later. The corrective procedure consisted of staged anterior and posterior fusion with instrumentation (six patients), posterior fusion with instrumentation (five), staged anterior fusion, posterior osteotomy and fusion with instrumentation (four), posterior osteotomy and fusion with Harrington instrumentation (one). Anterior decompression was also performed in 5 of the 10 patients who had anterior fusion. There was no major perioperative complication. Pain was relieved in 13 patients and 9 of 11 had substantial neurologic improvement. Two patients had nonunion of posterior grafts, but these united after revision. The mean loss of correction in the early postoperative period was 3.5 degrees. The authors conclude that surgical treatment of post-traumatic symptomatic progressive kyphosis is effective and safe.     

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.     

Posterior reduction and anterior lumbar interbody fusion in symptomatic low-grade adult isthmic spondylolisthesis: short-term radiological and functional outcome

The aim of this study was to evaluate the short-term radiological and functional outcome of surgical treatment for symptomatic, low-grade, adult isthmic spondylolisthesis. Twelve patients underwent a monosegmental fusion for symptomatic spondylolisthesis. Posterior reduction with pedicle screw instrumentation was followed by second-stage anterior interbody fusion with a cage. All patients underwent a decompressive laminectomy. At an average of 2.1 (range 1.4-3.0) years following surgery, all patients completed the Oswestry questionnaire, VAS back pain score and a questionnaire detailing their work status. Radiographs were evaluated for maintenance of reduction and fusion. The patients (nine male, three female; mean age 42, range 22-54 years) had experienced preoperative symptoms for an average of 38 (range 6-96) months. An average preoperative slip of 21% (range 11-36%) was reduced to 7% (range 0-17%). Reduction of slip was maintained at latest follow-up, at which time the average VAS score was 2.8 (range 0-8) and the average Oswestry score was 13 (range 0-32). All patients achieved a successful fusion. There were no postoperative nerve root deficits. All patients stated that they would be prepared to undergo the same procedure again if required. Seventy-five percent returned to their pre-symptom work status. Our findings suggest that posterior reduction and anterior fusion for low-grade adult isthmic spondylolisthesis may yield good functional short-term results. A high fusion rate and maintenance of reduction with a low complication rate may be expected. Further follow-up is necessary to evaluate long-term outcome.     

Complete rotational burst fracture of the third lumbar vertebra managed by posterior surgery. A case report

STUDY DESIGN: Case report of a young man with rotational burst fracture of the third lumbar vertebra, treated by posterior surgery. OBJECTIVES: To describe the management of a rotational burst fracture of the third lumbar vertebra by posterior surgery consisting of reduction, decompression, fusion, and transpedicular instrumentation. SUMMARY OF BACKGROUND DATA: Surgery is the generally recommended means of managing lumbar burst fractures with neurologic deficit. Some surgeons recommend anterior decompression, fusion, and instrumentation. Posterior surgery with decompression through laminectomy, spongioplasty of the vertebral body, interbody fusion of damaged discs, posterolateral fusion, and transpedicular fixation is also a safe and successful management technique. The combined approach consists of posterior decompression, fusion, transpedicular fixation, and anterior fusion using pelvic autografts. The optimum method of management remains in question. METHOD: An 18-year-old man with complete rotational burst fracture of the third lumbar vertebra was treated by posterior surgery. This surgery consisted of reduction, laminectomy, decompression, structure of dural sac tears, spongioplasty of the vertebral body, interbody fusion of both damaged discs, and the implantation of a transpedicular Socon fixator (Aesculap, Tuttlingen, Germany), including a transverse connector. The case was documented by radiographs and computed tomography scans before surgery and after fixator removal 19 months after surgery. RESULTS: The patient healed solidly with no instrumentation failure. The neurologic deficit Frankel Grade B improved to Frankel Grade D. CONCLUSION: Surgery to manage lumbar burst fracture must include reduction, decompression, restoration and fusion of anterior and posterior elements by using autologous pelvic spongious autografts, and anterior or posterior instrumentation. Posterior surgery including suturing of dural sac tears, fusion of damaged structures, and transpedicular fixation is successful in young patients and patients with good bone quality.     

One-stage decompression and posterolateral and interbody fusion for severe spondylolisthesis. An analysis of 14 patients

STUDY DESIGN: A retrospective study of 14 patients with high-grade L5-S1 spondylolisthesis surgically treated with one-stage decompression and posterolateral and interbody fusion (technique of Bohlman and Cook). OBJECTIVE: To determine the efficacy of this technique in managing severe lumbosacral spondylolisthesis. SUMMARY OF BACKGROUND DATA: Controversy exists over the most appropriate method for managing high-grade spondylolisthesis. Circumferential in situ fusion from a single-stage posterior approach was described in 1982, but to the current authors' knowledge, there are not many reports on clinical results in the literature. The current authors studied 14 patients (mean age, 21 years) with severe L5-S1 spondylolisthesis. The percentage of slipping averaged 77%; slip angle averaged 36 degrees. The average follow-up period was 30 months. All patients had severe back or radicular symptoms. Two patients had foot drop, and four had minor neurologic dysfunction. Four patients had extremely tight hamstrings. METHODS: Pre- and postoperative radiographic films and computed tomography scans were reviewed. Magnetic resonance imaging was carried out in 11 patients before surgery and at follow-up examination. Patients were evaluated for fusion rate, clinical outcome, and complications. RESULTS: All six patients with motor deficit of the nerve roots showed complete strength recovery at follow-up examination. None of the patients had tightness of hamstrings. Twelve patients demonstrated incorporation of the graft with solid fusion, one patient had a fracture of the fibular graft, and one had graft resorption. All patients but one rated the surgical result as excellent. One patient was not satisfied with the cosmetic result. Transient paresthesias in the leg of the donor graft were documented in two patients. CONCLUSIONS: Posterior decompression of the spinal canal combined with anterior and posterior arthrodesis performed at one stage through a posterior approach is a safe and effective technique for managing severe spondylolisthesis.     

Aneurysmal bone cyst of the second cervical vertebrae causing multilevel upper cervical instability

OBJECTIVE: Aneurysmal bone cyst (ABC) is a rare expansile osteolytic lesion of bone comprising proliferating vascular tissue lining blood-filled cystic cavities. ABCs occur most frequently in patients under age 20 and are uncommon after 30 years of age. Three to 20% of cases occur in the spine, and upper cervical involvement is rare. Lesions may grow rapidly and attain considerable size. When involving the spine, ABCs may result in instability and neurologic compromise, making prompt diagnosis and treatment imperative. We present a report of a 6-year-old child with an ABC of the second cervical vertebrae causing atlantoaxial and C2-C3 instability, treated successfully with curettage, decompression, and anterior and posterior arthrodesis with posterior instrumentation. METHODS: The patient underwent a staged procedure consisting of posterior instrumentation from occiput to C4 and curettage of the lesion followed by anterior cervical discectomy and fusion of C2-C4. The diagnosis, surgical treatment, and outcome of the case are described and relevant literature reviewed. RESULTS: The patient sustained no lasting neurologic deficits and was disease-free at 3 years of follow-up. CONCLUSIONS: ABC is a rare but potentially devastating cause of upper cervical spine instability. Prompt detection and treatment with curettage, decompression, and fusion can produce a satisfactory result and prevent spinal cord injury.     

Management of adult spinal deformity with combined anterior-posterior arthrodesis and Luque-Galveston instrumentation.

Twenty-five consecutive adult women with nonparalytic spinal deformity were treated with fusion to the sacrum. Two patients were lost to follow-up and one patient died, leaving 22 patients for review. All patients underwent a first-stage anterior spinal fusion without instrumentation followed by a second-stage posterior spinal fusion with Luque-Galveston instrumentation. The average age of the patients was 47 years (range, 25-64 years). The average follow-up was 39 months (range, 24-60 months). Ten patients had had previous surgery in the area of the instrumentation. The main indications were pain (22 patients), loss of sagittal plane balance (17 patients), and progression of the deformity (13 patients). Additional procedures included anterior corpectomies (five patients), anterior and posterior osteotomies (two patients), posterior osteotomies (eight patients), and posterior decompression (five patients). The average curve correction was 27% for thoracic scoliosis and 44% for lumbar scoliosis. Physiologic sagittal plane realignment was obtained in four patients who presented preoperatively with sagittal plane deformities. Pain improvement was reported in 14 of 22 (63%) patients. Nineteen (82%) patients had 34 complications. Pseudarthrosis occurred in nine patients (41%) and was successfully repaired in four; hence the fusion rate was 77% at follow-up. Of the 23 patients, one died from pulmonary embolism, 15 (66%) were in good condition, one (4%) was in fair condition, and seven (30%) were in poor condition. Previous surgery and additional procedures such as vertebrectomies or osteotomies did not adversely affect the outcome. There were no permanent neurologic deficits related to the instrumentation or the passage of sublaminar wires. The Luque-Galveston method provided correction of sagittal plane deformities and flatback syndrome.     

Cervical spondylosis: the role of anterior instrumentation after decompression and fusion

The role of plate stabilization after anterior decompression and fusion of the cervical spine for cervical spondylosis remains controversial. This study aimed to justify the use of instrumentation to stabilize anterior cervical fusion for cervical spondylosis through a risk-benefit analysis and comparison of the results with those reported in the literature on the outcome of fusion without instrumentation. The authors retrospectively reviewed the charts and radiographs of 47 patients with symptoms secondary to cervical spondylosis who underwent anterior cervical decompression and instrumented fusion. After operation, patients were mobilized early, and neither neurologic injury nor infection developed in any patient. At an average 3.4 years after surgery, the rate of graft complications, including nonunion (4.26%), was low, whereas the rate of hardware-related morbidity was minimal (6%). An average 0.4 degrees loss of the intraoperative correction of cervical lordosis was observed at the last follow-up examination. Accelerated degenerative changes at levels adjacent to the fusion were seen in 17% of patients, but only two patients required repeat operation for persistent symptoms. The use of instrumentation to stabilize the cervical spine in patients with cervical spondylosis after anterior decompression and fusion is relatively safe. It permits early pain-free mobilization, successfully maintains sagittal cervical spine alignment, and promotes consistent and reliable spinal fusion.     

Comparison of open and minimally invasive techniques for posterior lumbar instrumentation and fusion after open anterior lumbar interbody fusion

Background contextMinimally invasive techniques for spinal fusion have theoretical advantages for the reduction of iatrogenic injury. Although this topic has been investigated previously for posterior-only interbody surgery, such as transforaminal lumbar interbody fusion, similar studies have not evaluated these techniques after anteroposterior spinal fusion, a study design that can more accurately determine the effect of pedicle screw placement and decompression via a minimally invasive technique without the confounding effect of simultaneous interbody cage placement.PurposeTo compare process measures that provide insight into the morbidity of surgery, such as surgical time and the length of postoperative hospital stay between open and minimally invasive anteroposterior lumbar fusion; and to compare the complications during the intraoperative and early postoperative period between open and minimally invasive anteroposterior lumbar fusion.Study designRetrospective case-control study.Patient sampleOne hundred sixty-two patients.Outcome measuresEstimated blood loss, length of surgery, intraoperative fluoroscopy time, length of postoperative hospital stay, malpositioned instrumentation on postoperative imaging, and postoperative complications, including pulmonary embolus and surgical site infection.MethodsPatients who underwent open anterior lumbar interbody fusion followed by either traditional open posterior fusion (Open group) or minimally invasive posterior fusion (minimally invasive surgery [MIS] group) were matched by the number of surgical levels. A chart review was performed to document the intraoperative and postoperative process measures and associated complications in the two groups. Secondary analyses were performed to compare the subgroups of patients, who did and did not undergo a posterior decompression at the time of posterior instrumentation to determine the effect of decompression.ResultsBaseline characteristics were similar between the Open and MIS groups. Estimated blood loss and postoperative transfusion rate were significantly higher in the Open group, differences that the subanalyses suggested were largely because of those patients who underwent concomitant decompression. Length of stay was not significantly different between the groups but was significantly shorter for MIS patients treated without decompression than for Open patients treated without decompression. Intraoperative fluoroscopy time was significantly longer in the MIS group. There was no difference in the infection or complication rates between the groups.ConclusionsOur case-control study comparing patients who underwent anterior lumbar interbody fusion followed by open posterior instrumentation with those who underwent anterior lumbar interbody fusion followed by minimally invasive posterior instrumentation demonstrated that patients undergoing MIS fusion without decompression had less blood loss, less need for transfusion in the perioperative period, and a shorter hospital stay. In contrast, most outcome measures were similar between MIS and Open groups for patients who underwent decompression.     

Posterior instrumentation surgery for thoracolumbar junction injury causing neurologic deficit

Thoracolumbar junction (TLJ) injury is one of the most common spine injuries. TLJ injury manifesting as neurologic deficit usually requires surgery because of the underlying spinal instability and/or neural compression. The objectives of surgical treatment are to restore biomechanical stability of the spine and/or to achieve neural decompression. The short-term outcomes were evaluated of 32 patients with symptomatic TLJ (T11-L2) injury who underwent posterior instrumentation surgery in the acute stage between 2000 and 2004. Seventeen patients had unstable burst fracture and 15 patients had either flexion-distraction or fracture-dislocation injury of the TLJ. Fifteen patients had American Spinal Injury Association (ASIA) classification Grade-A, eight had Grade-B, seven had Grade-C, and two had Grade-D preoperative neurologic deficits. All patients underwent posterior instrumentation surgery using pedicle screws and connecting rods, fixed to two vertebral levels above and below the injured segment. No patient experienced neurologic deterioration perioperatively. Postoperative recovery evaluated 3 months after discharge heavily depended on the preoperative neurologic status: patients with ASIA Grade-A deficits usually had limited neurologic recovery, whereas some with Grade-C or D became ambulatory. Complications occurred in five patients, but none suffered death or permanent morbidity. Posterior instrumentation surgery is a safe and efficacious treatment for patients with symptomatic TLJ injury. Long-term efficacy of the posterior instrumentation surgery is less clear, because of the limited duration of the follow-up period.     

Minimally invasive anterior lumbar interbody fusion followed by percutaneous pedicle screw fixation for isthmic spondylolisthesis.

BACKGROUND CONTEXT: Most surgeons have thought that posterior decompression is necessary to treat isthmic spondylolisthesis with leg pain. However, the surgical procedure not only requires wide muscle dissection but can also lead to spinal instability. The authors' treatment concept for isthmic spondylolisthesis is one-stage anterior reduction and posterior stabilization with minimally invasive surgical procedure without touching the spinal thecal sac and nerve. PURPOSE: To investigate a new surgical concept of minimally invasive anterior-posterior fusion without posterior decompression for the treatment of isthmic spondylolisthesis with leg pain. STUDY DESIGN: This is a retrospective study of 73 patients with isthmic spondylolisthesis who underwent minimally invasive anterior lumbar interbody fusion (mini-ALIF) followed by percutaneous pedicle screw fixation (PF) between October 2000 and February 2002. PATIENT SAMPLE: A total of 73 patients with low-grade isthmic spondylolisthesis (46 with Grade 1 and 27 with Grade 2) who underwent mini-ALIF followed by percutaneous PF were retrospectively analyzed. There were 20 men and 53 women, with a mean age of 50.6 (range, 19 to 77) years. All patients had low back pain and referred or radicular leg pain or neurogenic intermittent claudication in walking or standing. Average duration of symptoms was 26 (range, 3 to 120) months. OUTCOME MEASURES: The clinical outcome was graded according to the modified Macnab criteria. METHODS: The authors retrospectively reviewed clinical and radiological data of 73 patients who had isthmic spondylolisthesis. All patients underwent mini-ALIF and percutaneous PF on the same day between October 2000 and February 2002. The mean follow-up period was 16 months (range, 12 to 26). RESULTS: The mean operating time, blood loss and hospital stay were 210 minutes, 135 ml and 4.1 days, respectively. No blood transfusion was necessary. Clinical outcome was excellent in 26 patients (35.6%), good in 43 (58.9%), fair in 3 (4.1%) and poor in 1 (1.4%). The fusion rate was 97.3% (71 of 73). There were 6 cases (8.2%) of mini-ALIF complications and 6 (8.2%) of percutaneous PF complications. There were no postoperative neurologic deficits. CONCLUSIONS: Mini-ALIF followed by percutaneous PF is an efficacious alternative for low-grade isthmic spondylolisthesis, and posterior decompression is not necessary to relieve leg symptoms. This minimally invasive combined procedure offers many advantages, such as preservation of posterior arch, no nerve retraction, less blood loss, excellent cosmetic results, high fusion rate and early discharge.     

Complications in the surgical treatment of pediatric high-grade, isthmic dysplastic spondylolisthesis. A comparison of three surgical approaches.

STUDY DESIGN: An analysis of consecutive pediatric patients treated surgically for high-grade spondylolisthesis by one of three surgical procedures with emphasis on complications and functional outcomes. OBJECTIVE: Complications, radiographic results and patient-assessed function, pain, and satisfaction were assessed among three surgical procedures. SUMMARY OF BACKGROUND DATA: The existing literature is in disagreement about whether it is better to fuse without instrumented reduction or to use instrumentation and reduce high-grade dysplastic spondylolisthesis. METHODS: Thirty-two patients had 37 surgical procedures for Meyerding Grade 3 or 4 isthmic dysplastic spondylolisthesis. Eleven patients were treated with an in situ L4-sacrum posterior fusion without decompression (Group 1), 7 had posterior decompression with posterior instrumentation and posterior fusion (Group 2), and 19 patients had reduction and a circumferential fusion procedure (Group 3). All patients had new radiographs taken at time of follow-up (average, 3.1 years; range, 2 years-10 years, 1 month) and completed a functional outcome questionnaire. RESULTS: The incidence of pseudarthrosis was 45% (5 of 11) in Group 1, 29% (2 of 7) in Group 2, and 0% (0 of 19) in Group 3. All seven who had pseudarthrosis had small L5 transverse process surface area (< 2 cm2; P = 0.004). Only one patient had a neurologic deficit (unilateral extensor hallucis longus weakness) at time of follow-up. There were no significant differences among the groups in function, pain, and satisfaction in patients in whom solid fusion was obtained, but the scores were highest in Group 3. CONCLUSIONS: In situ fusion surgery in patients with high-grade spondylolisthesis with small L5 transverse processes (surface area, < 2 cm2) results in a high rate of pseudarthrosis. Circumferential procedures result in the highest rate of fusion and are effective in achieving fusion in those patients with established pseudarthrosis. The use of long (> 60 mm) iliac screws bilaterally (n = 21) in addition to bicortical sacral screws (four-point sacral-pelvis fixation) along with anterior column fusion reduces the risk of instrumentation failure in a decompression and reduction procedure. Outcomes of function, pain, and satisfaction are excellent in those in whom fusion is achieved. The risks in circumferential fusion-reduction procedures are acceptable.     

Treatment of spondylolysis and spondylolisthesis with Cotrel-Dubousset instrumentation: a preliminary report.

We treated 50 consecutive patients with Cotrel-Dubousset instrumentation (CDI) for symptomatic spondylolisthesis. Average follow-up was 25 months. Fusion in situ was performed in 32 of 44 patients with mild spondylolisthesis, while 12 patients had reduction in conjunction with neural decompression. Two of six patients with severe spondylolisthesis who were treated via a single posterior approach had loss of reduction and nonunion. In another patient a Grade III spondylolisthesis could not be reduced via a posterior approach. Seventy-six percent of the patients had a good clinical result. The rate of solid fusion was 96%. One nerve root compromise recovered completely. One superficial wound infection healed uneventfully. This study suggests that combined anterior and posterior fusion is required for permanent and sufficient correction of severe spondylolisthesis even with CDI. Low-grade spondylolisthesis should be reduced only in conjunction with neural decompression.