Diagnosis and treatment of severe dysplastic spondylolisthesis.

Spondylolisthesis, the anterior or posterior displacement of one vertebra on another, usually affects the lumbar region. Five percent of the population has one of the five classes of spondylolisthesis, which include dysplastic, isthmic, degenerative, traumatic, and pathologic spondylolisthesis. This article focuses on the dysplastic type, which makes up 14% to 21% of all spondylolisthesis. Dysplastic spondylolisthesis usually causes no symptoms in children; pain usually begins in adolescence. The key to diagnosis is the appropriate use of radiography in the evaluation of low back pain. This report describes a case involving a 21-year-old woman presenting with back pain to the family physician. Also, it details how the diagnosis was achieved and evaluates conservative and aggressive treatment options.     

Spinal arthrodesis for severe spondylolisthesis in children and adolescents. A long-term follow-up study

The long-term results of spinal arthrodesis were evaluated in fourteen children and adolescents who had severe spondylolisthesis. Twelve patients had an in situ posterior arthrodesis and the other two had, in addition, open reduction. The two patients who had open reduction lost correction when the rods were removed. At long-term follow-up, which averaged 11.9 years, all patients had a solid fusion and their activities were unrestricted. Two patients were dissatisfied with the cosmetic result. No intraoperative or postoperative complications occurred in association with the in situ arthrodeses that were performed alone. Posterior in situ arthrodesis proved to be an effective, reliable, and safe treatment for severe spondylolisthesis.     

Treatment of severe spondylolisthesis by anterior and posterior reduction and stabilization. A long-term follow-up study

Twenty-two consecutive unselected patients who had severe spondylolisthesis were treated by a first-stage posterior decompression (Gill procedure) and a posterolateral arthrodesis, followed by halo-skeletal traction, and then by a second-stage anterior interbody arthrodesis, followed by immobilization in a cast. Nineteen patients had complete clinical and radiographic evaluation, with an average follow-up of five years (range, two to seven and one-half years). The slip angle averaged 71 degrees preoperatively, was corrected to an average of 31 degrees by reduction, and averaged 28 degrees at follow-up. The average preoperative percentage of slippage (98 per cent) did not change substantially. A pseudarthrosis developed in four patients, all of whom had a reoperation. The neurological deficits that had been present in ten patients preoperatively had completely resolved in all but one at follow-up. One patient had a cauda equina syndrome and two patients had a neuropathy of the root of the fifth lumbar nerve as a result of the reduction; complete recovery occurred in two patients and partial recovery, in one. Alignment in the sagittal plane was restored in seventeen patients, and the back pain and radicular symptoms were relieved in all patients except one who had had those symptoms preoperatively.     

Urethral pull-through operation and long-term follow-up

Pull-through urethroplasty is appropriate for acute or delayed treatment of lesions of the membranous and proximal bulbar urethra. The length of the structure itself appears to be more important in predicting success than the precipitating event which produces the structure.     

Extended anterior cervical decompression without fusion: a long-term follow-up study

We report the long-term outcome in 80 patients who had undergone extended anterior cervical decompression without fusion for cervical nerve root or spinal cord compression. Follow-up ranged from 2 years 4 months to 13 years. Five patients had died from causes unrelated to the original pathology or the surgery. Of the remaining 75 patients, 66 (88%) were symptom free or clearly improved, eight (10%) were unchanged and one patient (1.5%) was worse. Sixty-eight patients (91%) were satisfied with the outcome of treatment. Nineteen patients (25%) had some degree of residual neck pain, but in none was this a major problem. Three patients had required subsequent surgery for cervical disc protrusions at levels adjacent to the first operation, while two patients had developed foraminal stenosis at the level of the surgery and had undergone foraminotomy. One patient had developed a symptomatic flexion deformity. Radiological assessment revealed bony fusion in 71%, some degree of flexion deformity in 13% and some degree of foraminal stenosis in 38%. Our results suggest that the initial good results of extended anterior cervical decompression without fusion are maintained long-term. Although a small number of patients eventually develop problems that might be avoided by an initial spacing procedure/formal fusion, these are no greater than the immediate problems associated with the harvesting and insertion of a bone graft.     

Combined dysplastic and isthmic spondylolisthesis: possible etiology.

STUDY DESIGN: Four cases of combined dysplastic and higher-level isthmic spondylolisthesis were studied. OBJECTIVE: To attempt to understand the possible etiology of this unreported combination. SUMMARY OF BACKGROUND DATA: Dysplastic spondylolisthesis is thought to be hereditary. It is believed that isthmic spondylolisthesis, the more common type, is acquired. Multiple spondylolysis and spondylolisthesis have been reported, but no cases of combined dysplastic and isthmic spondylolisthesis. METHODS: The global and segmental Cobb angles of the lumbar vertebrae and sagittal vertical alignment were measured in four patients who presented with lower back pain and varying degrees of pain radiation to the lower limb. Posteroanterior and lateral radiographs were taken with patients standing barefooted. Three of the patients underwent surgery. The fourth patient refused surgery. RESULTS: The global and segmental Cobb angles were found significantly increased in these patients. Increased segmental extension angles were clearer at the levels above the dysplastic vertebrae and at the level of the isthmic defect. Large anterior translation of the thorax was noted in all cases. CONCLUSIONS: The authors believe that this unusual combination may have resulted from hyperlordosis occurring above the dysplastic vertebrae, which caused increased stresses that led to the isthmic defect. This combination should be investigated in patients with dysplastic spondylolisthesis and hyperlordosis.     

无内固定前路手术治疗腰椎滑脱症

目的探讨不加任何内固定手术治疗峡部裂性腰椎滑脱的可行性,评估复位率、融合率以及疗效,以帮助无能力支付内固定物费用的患者.方法选择Meyerding法Ⅱ°以内的峡部裂腰椎滑脱症36例,经前路腹膜外减压、复位,21例自体髂骨块2块,15例深低温异体骨圈复合自体松质骨,做椎体间嵌植融合,术后离床活动,支具外固定3～6个月.结果35例随访1～10年,复位率Ⅱ°者＞50%,Ⅰ°者超过85%.除1例骨块向前移位吸收需二期手术外,余34例获得骨性融合,融合率97.1%,优良率94.3%,每例节省费用2～3万元.结论无内固定前路手术可以安全、可靠治疗Ⅰ～Ⅱ°峡部裂性腰椎滑脱症.     

Jarcho-Levin syndrome: report on a long-term follow-up of an untreated patient

Jarcho-Levin syndrome is a genetically transmitted rare entity characterized by multiple vertebral and rib anomalies. The multilevel skeletal involvement causes short stature, neck and thoracic cage deformities, and restrictive lung disease that is usually the cause of early death. The authors describe a 33-year follow-up of a patient with this syndrome who represents, to their best knowledge, the longest survival of a patient with this entity.     

Outcome of intensive rehabilitation after severe brain injury: a long-term follow-up study

Fifty-five brain-injured adults (of 64 discharged) were followed up from 19 to 101 months after discharge from a rehabilitation unit. Change was assessed in terms of discharge and current placement, as compared with pre-admission placement. The results demonstrate that rehabilitation achieved improvements in functional skills and social behaviour that lastingly affected the type of placement possible, and thus improved quality of life. In most cases where improvements were seen during rehabilitation, further improvements occurred after discharge. The findings also have implications for the timing of rehabilitation and for discharge and resettlement planning.     

Coronary artery operation in radiation-associated atherosclerosis: long-term follow-up.

Radiation-associated coronary atherosclerosis is a potential problem for patients who have had mediastinal irradiation for malignant tumors. This study identified 14 patients with radiation-associated coronary atherosclerosis, defines unique population characteristics, and analyses postsurgical problems and long-term outcome. Fourteen patients with radiation-associated coronary atherosclerosis and class III and IV New York Heart Association symptoms were identified because of mediastinal or chest wall irradiation (30 Gy) associated with anterior epicardial discoloration or fibrosis, aortitis with adventitial thickening, and inflammatory process over a proximal coronary artery. Two distinct treatment groups were analyzed. Coronary artery operation resulted in one hospital death, with vein grafts being used predominantly. The internal mammary artery could only be used in 3 patients because of vessel friability and mediastinal fibrosis. Postoperative right ventricular dysfunction and pulmonary problems were frequent. Severe pericardial inflammatory complications (fibrosis with graft closure, and constrictive pericarditis) present in 2 early patients resulted in routine anterior pericardiectomy after coronary artery operation without further problems. Long-term follow-up (100%) (range, 11 to 74 months) revealed that 1 patient died late and of the remainder (12 patients), 11 were in New York Heart Association class I and 1 in class II, experiencing three myocardial events. Thus, patients with radiation-associated coronary atherosclerosis have a low operative mortality but have risk of early right ventricular and pulmonary dysfunction. The routine use of internal mammary artery may not be possible and anterior pericardiectomy is recommended. Long-term results are excellent and no evidence of accelerated disease has been noted.     

Solid fusion vs. non-union in long-term follow-up of in situ fusion without internal fixation in symptomatic spondylolisthesis in young patients

Summary A clinical and radiological long-term follow-up study is presented of 175 patients under the age of 20 years operated on for symptomatic isthmic spondylolisthesis of L5. The mean observation time was 15 years (range 5–30 years). There were 89 female and 86 male patients; mean age at operation was 14.8 years. Posterior fusion was carried out in 112 cases, posterolateral fusion in 60 and anterior fusion in 3; a concomitant laminectomy was performed in 34 cases. One segment (L5-S1) was fused in 54 patients, two segments (L4-S1) in 104, and three segments (L3-S1) in 17. Autogenous cortico-spongeous bone was used in 119 cases and free periosteal grafts in 56. At follow-up, solid bony fusion was found in 145 patients; 30 patients (17.1%) had non-union. The data for these two groups were compared statistically. The frequency of non-union was significantly higher after posterior than after posterolateral fusion (P<0.05), in two-level fusions than in one-level fusions (P=0.003), and in cases where periosteal rather than cortico-spongeous bone grafts had been used (P<0.01). The posterior fusion technique using periosteal grafts gave the highest rate of non-unions, whereas the posterolateral technique with cortico-spongeous grafts gave the highest rate of successful fusions (P<0.001). Non-union occurred significantly more often in cases of grade I slip (36%) than in cases of grade II (7%), III (8%) or IV slip (0%). The higher frequency of non-unions in grade I slips was associated with more frequent use of the posterior fusion technique in cases of minor or moderate grades of slip. The duration of postoperative bed rest or duration of immobilization in a corset had no statistically significant influence on fusion rate. The rate of non-union had no statistically significant association with the long-term clinical result. Postoperative pain symptoms, however, lasted longer in non-union patients (mean 14.2 months) than in successfully fused patients (mean 4.5 months; P<0.01). The results show the benign nature of the condition, which seems to be a self-limiting process leading to stabilization of the affected segment. The posterolateral fusion technique using autogenous cortico-spongeous bone grafts is recommended as the method of choice for most cases.     

A review of the Yasui operation with long-term follow-up of a case

Yasui operation combines Norwood arch reconstruction with Rastelli operation for interrupted or hypoplastic aorta with aortic valvar atresia or hypoplasia with ventricular septal and two adequately sized ventricles, establishing biventricular repair. We present a case of aortic atresia, mitral hypoplasia, and ventricular septal defect (VSD) treated by Yasui procedure, and its long-term (108 months) follow-up and brief review of literature. Review of literature was done using keywords to search on “PubMed” and “Google Scholar.”Supplementary InformationThe online version contains supplementary material available at 10.1007/s12055-021-01174-5.     

The Chiari pelvic osteotomy for patients with dysplastic hips and poor joint congruency: long-term follow-up

We report the mid- to long-term (mean 20.3 years, 10 to 32.5) results of the Chiari pelvic osteotomy in patients with pre- to advanced stage osteoarthritis in dysplastic hips. We followed 163 Japanese patients (173 hips) with a mean age at surgery of 20 years (9 to 54). Overall, 124 hips (72%) had satisfactory results, with Harris hip scores ≥ 80. Satisfactory results were seen in 105 of 134 hips with pre- or early osteoarthritis (78%) and 19 of 39 hips with advanced osteoarthritis (49%). A total of 15 hips (9%) underwent a total hip replacement (THR) with a mean interval between osteotomy and THR of 16.4 years. With conversion to THR as the endpoint, the 30-year survival rate was 85.9% (95% confidence interval 82.3 to 89.5). It was 91.8% for patients with pre- or early osteoarthritis and 43.6% for those with advanced osteoarthritis (p < 0.001). We now perform the Chiari osteotomy for patients with dysplastic hips showing poor joint congruency and who prefer a joint-conserving procedure to THR.     

Progression of spondylolisthesis in children and adolescents. A long-term follow-up of 272 patients

The radiologic progression of spondylolisthesis during a long-term follow-up was studied in 272 children and adolescents. There were 134 girls and 138 boys. The mean age at the first visit was 14.3 years (girls, 13.8 years; boys, 14.9 years). The radiologic follow-up time was 14.8 years on average (range, 5-32). The operation was done in 190 patients younger than 20 years of age. Fusion in situ, using a posterior or posterolateral technique, had no statistically significant effect on progression. Surgically treated patients did not differ from conservatively treated patients. Ninety percent of the slip, on average, had already occurred at the first radiologic examination compared with the final amount of slip. More than 10% progression occurred in 62 patients, mainly within the first year postoperatively or after the first examination. Progression of the lumbosacral kyphosis and sinking of the vertebral body was noted in severe slips. Although female gender and dysplasia (spina bifida) at the lumbosacral junction were more frequent in severe slips, they statistically had no value in predicting progression. A wedge form of L5 or sacral rounding also had no prognostic value. These were secondary to the slip and expressed it but did not predict it. The only radiologic variable with predictive value of progression was the percentage amount of the primary slip. In age groups corresponding to the growth spurt in early puberty (girls, 9-12 years; boys, 11-14 years), there was a tendency to progress.     

Disc degeneration in young patients with isthmic spondylolisthesis treated operatively or conservatively: A long-term follow-up

The purpose of this longterm follow-up was (1) to investigate disc changes in the olisthetic segment in patients treated conservatively, (2) to compare disc changes above the slipped vertebra in conservatively treated patients with those in operatively treated patients, and (3) to establish possible relations of disc changes to the degree of the slip and to subjective back pain symptoms of the patients. The subjects were 227 patients with isthmic L5 olisthesis diagnosed under 20 years of age (mean 13.8 years) with a mean follow-up of 15.4 (range 5–30) years. Of these, 145 patients had been treated with segmental fusion and 82 had been treated conservatively. At follow-up, standing anteroposterior and lateral radiographs as well as flexion/extension views of the lumbar spine were taken. Disc degeneration was graded semiquantitatively: 0 = normal disc height, 1 = decrease of disc height < 50%, 2 = decrease 50%, and 3 = obliteration of the disc. In the conservatively treated patients degeneration of the olisthetic disc was distributed by grade as follows: 0:n = 38, 1:n = 24, 2:n = 14, 3:n = 6. No motion at all was observed in the olisthetic segment in 40 patients (48%) with a mean slip of 30%,, segmental motion of 4°–18° was found in 42 patients with a mean slip of 14%. There was a statistically significant association of the degree of slip to the severity of disc degeneration and non-mobility of the segment. Grade 1 degeneration of the L4/5 disc occurred in 25.6% of the conservatively treated patients and in 32% of 48 patients treated with L5-S1 fusion. This correlated with the severity of the slip, but not with pain symptoms or pathologic segmental mobility at the time of follow-up. Out of 84 patients with L4-S1 fusion, in 17% grade 1 degeneration of the L3/4 disc was observed, and 3 out of 13 patients (23%) with L3-S1 fusion had grade 1 degeneration of the disc above the fusion. The disc changes had no correlation with subjective pain symptoms. It is concluded that the natural course of isthmic spondylolisthesis is associated with disc degeneration and spontaneous stabilization of the olisthetic segment. Fusion operations do not significantly increase the rate of disc degeneration in the adjacent disc above the fusion after a mean postoperative follow-up of 13.8 years. No correlation between the number of degenerated discs or the degree of degeneration and subjective low back pain symptoms was found.     

Reduction of high-grade isthmic and dysplastic spondylolisthesis in 5 adolescents

Treatment of high-grade isthmic and dysplastic spondylolisthesis in children and adolescents remains a challenge. Surgical treatment of spondylolisthesis has been recommended in adolescents with pain refractory to nonoperative modalities, slippage progression, or > 50% slippage on presentation. Controversy exists as to the optimal surgical approach for high-grade spondylolisthesis. In this report, we describe 5 cases of high-grade isthmic and dysplastic spondylolisthesis in adolescents and review the literature on surgical treatment for this entity. Operative records, charts, x-rays, and Scoliosis Research Society outcome questionnaires (SRS-22) were retrospectively evaluated for 5 consecutive patients diagnosed with and treated for high-grade spondylolisthesis. Each patient received treatment consisting of decompression, reduction, and circumferential fusion with transpedicular and segmental fixation from a posterior approach. Two patients had transient L5 nerve root deficit, which resolved within 3 months. Reduction benefits include a decrease in shear stresses (and resulting decreased rates of postoperative pseudarthrosis and slip progression), restoration of sagittal alignment and lumbosacral spine balance, and improvement in clinical deformity.