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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 15  |  Issue : 3  |  Page : 407-413

Clinical and functional outcome analysis of posterior decompression and spinal fusion surgery in the management of lumbar and sacral listhesis: A prospective cohort study


Department of Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi, Wardha, Maharashtra, India

Date of Submission01-Jul-2020
Date of Decision10-Jul-2020
Date of Acceptance30-Jul-2020
Date of Web Publication1-Feb-2021

Correspondence Address:
Dr. Mahendra Gudhe
Department of Orthopaedics, Acharya Vinobha Bhave Rural Hospital, DMIMS, Sawangi, Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_245_20

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  Abstract 


Introduction: Spondylolisthesis resulting in low backache, radiculopathy, and neurological involvement is a very common clinical entity. Conservative and surgical managements are available for the treatment of spondylolisthesis. Cases with severe instability and neurological deficits that cannot be managed conservatively may require surgical intervention. According to the SPORT trial, posterior decompression and spinal fusion was found to be an effective treatment modality. The present study was undertaken with an aim to understand the functional and clinical effects of posterior decompression and spinal fusion at lumbosacral region in patients with listhesis. Purpose: The purpose of this study is to evaluate the clinical and functional outcomes of listhesis at lumbar and sacral region managed by posterior decompression and spinal fusion. Methods: This was a prospective randomized study involving patients above 18 years, having low backache with or without sciatica, and having neurological deficits. Listhesis was diagnosed clinically and on stress radiograms and magnetic resonance imaging. All patients who fit the inclusion criteria underwent posterior decompression and if needed spinal fusion for symptomatic management. Results: A total of 30 patients participated in this study, with 73.33% women and the rest 26.67% men (mean age 51.37 ± 12.70 years). The most commonly affected level was L4–L5 along with L5–S1 right below it. Out of 30 patients, three underwent posterior decompression and fixation without fusion while one was managed with laminotomy and discectomy. The remaining patients were managed with posterior decompression and intervertebral fusion which was mainly at the L4–L5 level. At 6 months of follow-up, the mean preoperative visual analog scale score which was 8.70 ± 0.83 was reduced to 1.53 ± 1.38 along with appreciable reduction in Japan Orthopedic Association and Oswestry index scores. Three patients had surgical site infections while one patient had no pain relief. Conclusion: Posterior decompression and spinal fusion is an effective way in the management of lumbosacral listhesis.

Keywords: Intervertebral body fusion, lumbosacral listhesis, posterior decompression


How to cite this article:
Angachekar D, Deshpande S, Gudhe M, Samal N, Khan S, Gupta S. Clinical and functional outcome analysis of posterior decompression and spinal fusion surgery in the management of lumbar and sacral listhesis: A prospective cohort study. J Datta Meghe Inst Med Sci Univ 2020;15:407-13

How to cite this URL:
Angachekar D, Deshpande S, Gudhe M, Samal N, Khan S, Gupta S. Clinical and functional outcome analysis of posterior decompression and spinal fusion surgery in the management of lumbar and sacral listhesis: A prospective cohort study. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Feb 25];15:407-13. Available from: http://www.journaldmims.com/text.asp?2020/15/3/407/308565




  Introduction Top


Back pain is a problem that has plagued humans for many thousands of years. The first report of backache and sciatica was seen in the historical text of Edwin Smith Surgical Papyrus written around 1550 BC.[1] Low back pain is among the most common human disabilities – a price man pays for the erect posture and every human being on the earth will experience back pain one time or the other in their life time. In developed countries, backache still continues to be the second most common cause for hospital visits.[2]

Spondylolisthesis is taken from the Greek words “Spondylo” which means spine and “Olisthesis” which means slippage. This term was first used by the Obstetrician Herbinaux in 1782.[3] The anterior translation of the cephalad vertebra relative to adjacent caudal segment is a common feature among all the different types of listhesis, whereas in cases of retrolisthesis, this is reversed.[4] Surgical methods of treatment may be considered in patients with backache along with radiculopathy, claudication pain (neurological in nature), and/or instability of the vertebral elements, which is seen with different grades of spondylolisthesis.

Various surgical treatment modalities that exist are (1) surgical decompression and (2) surgical decompression with anterior and/or posterior fusion with or without the correction of listhesis. With the help of multilevel fusion, deformity correction is performed. In patients affected with spondylolisthesis, those who have undergone fusion surgeries have proven to be far more successful than those treated with medical management or decompression alone. This is proved with the help of their clinical, radiographic, and functional outcomes.[5]

Degenerative and isthmic spondylolisthesis are the two main clinical entities seen in practice.[6],[7] Degenerative spondylolisthesis of the lumbar spine is predominantly seen at L4–L5 level. Radiologically, this type of listhesis usually shows a central canal stenosis and the patient presents with intermittent claudication. In contrast, in the latter, stenosis is primarily observed in the lateral recess and foramina. Here, the patient presents with radicular pain at L5–S1 level.[8],[9],[10]

This study was conducted with an aim to evaluate the clinic-functional outcome of surgical decompression and instrumented intervertebral fusion in patients suffering from lumbar degenerative and isthmic spondylolisthesis in rural population of Central India.


  Methods Top


A prospective cohort study was conducted from May 2018 to June 2020 at Datta Meghe Institute of Medical Sciences, Wardha. The institutional ethical committee validated this study. All patients who participated were of ages >18 years who had degenerative or isthmic lumbosacral listhesis diagnosed by clinical and radiological methods and not responding to conservative management for 3 months. Other inclusion criteria were people who experienced single- or double-level symptomatic disc with unilateral or bilateral leg pain (with/without motor and sensory deficit), which implies the involvement of a nerve root and chronic pain in the lower back. The exclusion criteria were patients who are skeletally immature, dysplastic, congenital, traumatic listhesis and those who had a previous spine surgery. Thirty patients diagnosed with lumbosacral spondylolisthesis took part in this study. Spondylolisthesis diagnosis was established on history, clinical examination, and radiographs of the lumbar spine, stress radiographs on flexion and extension [Figure 1], and magnetic resonance imaging (MRI) of the lumbosacral spine [Figure 2]. Patient's pain and function were assessed preoperatively and postoperatively based on Oswestry disability questionnaire, Japan Orthopedic Association (JOA), and visual analog scale (VAS) score.[11],[12],[13],[14] The details of the study were explained to patients in their own language, and informed consent was taken for their participation. A team of surgeons managed these cases with a considerably similar surgical method (surgical decompression by laminectomy and foraminotomy; spinal stabilization by intervertebral fusion, pedicle screw, and rod instrumentation). Fusion was performed by using autogenous bone graft from a local laminectomy site.
Figure 1: (a) Anteroposterior radiograph of lumbosacral spine. (b) Stress radiograph of lumbosacral spine in extension showing anterolisthesis of L5 over S1. (c) Stress radiograph in flexion showing anterolisthesis of L5 over S1

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Figure 2: (a) Sagittal view of magnetic resonance imaging of LS spine showing anterolisthesis of L5 over S1. (b) Coronal view of magnetic resonance imaging LS spine at L5–S1 level

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Intraoperative and postoperative complications were noted. On the 2nd postoperative day, removal of surgical drains was done in all patients along with the initiation of walking while wearing a rigid lumbosacral orthosis. Postoperative follow-up was done at 1 month, 3 months, and then 6 months. At each follow-up, an X-ray of the spine was observed (both anteroposterior and lateral views). The patient was assessed based on Oswestry disability questionnaire, JOA, and VAS score.[11],[12],[13],[14] The primary outcome was to assess the function of the patient postoperatively. All the data collected were entered in the Microsoft Excel sheet and then moved for review to SPSS Application Version 17 (SPSS Inc., Chicago, Ill., USA). Qualitative data were provided in the form of frequency and percentage and studied with the help of Chi-square test; meanwhile, quantitative data were presented and measured by t-test as the mean and standard deviation. The value to be statistically significant, the P < 0.05.

Ethical clearance

The Institutional Ethics Committee of DMIMSDU has approved the Research work proposed to be carried out at Jawaharlal Nehru Medical College, Sawangi(M), Wardha. Date: 9th Oct 2017 with Reference no DMIMS(DU)/IEC/2017/435.


  Results Top


All 30 patients' results were analyzed. Most patients were in the age group between 61 and 70 years (n = 11; 36.67%), with a mean age of 51.37 ± 12.70 years. 22 patients (73.33%) were females while the remaining 8 (26.67%) were males. 16 (72.72%) of the females in the study were postmenopausal. 70% of the study population was involved in hard labor or agricultural work. 8 patients (26.67%) had hypertension, 3 (10%) had diabetes mellitus, and 1 patient (3.33%) each had cardiac problems and thyroid problems. The mean weight among patients was 64.78 ± 6.32 kg, the mean height was 156.20 ± 13.68 cm, and the mean body mass index (BMI) was 26.62 ± 4.40 kg/m2. It was observed that majority of the patients were having normal BMI (43.33%) while 11 patients (36.67%) were overweight and 6 (20%) patients were obese. Most patients had a duration of symptoms for 1–2 years (43.33%) followed by < 1year (23.33%) and > 5years (23.33%). All patients had low backache (100%, n = 30) followed by radicular pain (86.67%, n = 26) and claudication (63.33%, n = 19). Abnormal reflexes (30%, n = 9), sensory deficit (26.67%, n = 8), and limb weakness (16.67%, n = 5) were the other signs that were elicited. Special tests that were positive were straight leg raising test (30%, n = 9) followed by reverse Lasegue test (30%, n = 9) and Airds test (26.67%, n = 8).

Eighteen patients had listhesis at L4–L5 level (60%) alone, 8 patients (26.67%) at L5–S1 alone, and 3 patients (10%) at L3–L4 level. One patient had listhesis at both L4–L5 and L5–S1 levels. According to Meyerding grading,[15] majority of the patients had Grade II listhesis (43.33%, n = 13) followed by Grade I listhesis (33.33%, n = 10) and Grade III listhesis (23.34%, n = 7). No patient had Grade IV or V listhesis. On conducting MRI of the lumbosacral spine in patients, the following findings were seen: lumbar canal stenosis (100%, n = 30) followed by ligamentum flavum hypertrophy (46.66%, n = 14), PIVD (36.67%, n = 11), instability (30%, n = 9), and spondylolysis (23.33%, n = 7). Most patients showed bilateral spinal cord compression (n = 24, 80.00%). The remaining 6 patients (20%) showed unilateral compression (left-sided compression [n = 4, 13.33%] and right-sided compression [n = 2, 6.66%]). Most commonly degenerated disc was L4–L5 disc (96.66%, n = 29), followed by L5–S1 (46.66%, n = 14), L3–L4 level (40%, n = 12), and L2–L3 level (6.66%, n = 2).

Majority of the patients had undergone posterior decompression and spinal fusion (86.67%, n = 26) [Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7] followed by posterior decompression and spinal fixation without fusion (10%, n = 3), and in one patient, laminotomy with discectomy (3.33%) was done. The levels of spinal decompression and intervertebral fusion are given in [Graph 1]. Four patients (13.33%) did not undergo intervertebral fusion. Two patients had fusions at both L4–L5 and L5–S1 levels.
Figure 3: (a) Stress radiogram in flexion showing anterolisthesis of L4 over L5. (b) Stress radiogram in extension showing anterolisthesis of L4 over L5. (c) Lateral radiogram of lumbosacral spine showing anterolisthesis of L4 over L5. (d) Anteroposterior view of the lumbosacral spine

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Figure 4: (a) Sagittal section of magnetic resonance imaging of the lumbosacral spine showing listhesis of L4 over L5. (b) Coronal section of magnetic resonance imaging of lumbosacral spine at the level of L4–L5 disc

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Figure 5: (a) Anteroposterior radiograph showing L4–L5 fixation with intervertebral fusion with cage at L4–L5 level at 1st month follow-up. (b) Lateral radiograph showing L4–L5 fixation with intervertebral fusion with cage at L4–L5 level at 1st month follow-up

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Figure 6: Anteroposterior and lateral radiograph showing L4–L5 fixation with intervertebral fusion with cage at 3rd month follow-up

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Figure 7: (a) Anteroposterior radiograph showing L4–L5 fixation with intervertebral fusion with cage at 6th month follow-up. (b) Lateral view showing L4–L5 fixation with intervertebral fusion with cage at 6th month follow-up

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It was observed that postoperative clinical parameters among patients were statistically significant compared to preoperative parameters (P < 0.05) [Graph 2].



A statistically significant reduction was established in VAS score of the patients who came for follow-up during the 6 months' period [Graph 3].



Here, the difference between the preoperative and postoperative Oswestry disability index (ODI) score was found to be statistically significant (P = 0.004) [Graph 4].



It was observed that preoperative disability score of bed bond among patients was more compared to postoperative final follow-up with statistical significant difference (24 vs. 0; P = 0.008). JOA score improved with a statistical significance in the postoperative period (P = 0.01) [Graph 5]. It was also noted that patients with normal BMI had more normal JOA score as compared to overweight and obese patients with statistical significant difference (P = 0.01).



Intraoperative and postoperative complications were noted. Majority of patients had postoperative neurodeficits (13.33%, n = 4) while 4 patients underwent re-exploration (13.33%). Surgical site infections (SSIs) were seen in 3 patients (10%). All 3 patients who had SSIs had  Escherichia More Details coli cultures on sending local swabs. Out of the patients who had SSIs, 2 developed postoperative unilateral foot drop. All 3 patients had to undergo re-exploration surgery. Intraoperative dural leak and intraoperative misplaced screws were observed in 4 (13.33%) and 2 (6.66%) patients, respectively. Out of the 2 patients who had misplaced screws, one patient had postoperative foot-drop and had to undergo re-surgery for replacing the screw, while the other patient underwent correction of the misplaced screw in the initial surgery itself and showed no postoperative complication. Both patients with intraoperative misplaced screws had dural leaks. Two more patients had dural leaks intraoperatively which were repaired intraoperatively with prolene 4-0 and patients had no postoperative complications. One patient (3.33%) had intractable pain postoperatively which was not relieved. This patient was managed with foraminotomy with discectomy. The pain may have been due to incomplete decompression of neural elements.


  Discussion Top


Degenerative spondylolisthesis is the acquired translation of the cephalad vertebra over the caudal vertebra due to degenerative process in the lumbosacral spine. Isthmic listhesis is due to the break or elongation of the pars interarticularis. Most of these listhesis respond to conservative management. Patients who develop sensory deficits, muscles weakness, cauda equina syndrome or pain, and radiculopathy which severely affect their function most likely need operative management.[16] The choice of surgery used in the treatment of spondylolisthesis is still a controversy.[17] Posterior decompression and spinal fusion is a good procedure for the management of symptomatic listhesis with spinal canal stenosis for good functional outcomes.[18]

In a study by Gille et al. on outcomes among degenerative spondylolisthesis patients, it was observed that slippage was situated at L2–L3, L3–L4, L4–L5, and L5–S1 in 3%, 18%, 73%, and 6%, of the cases, respectively. Further, 12% cases had >1 level involved. The ODI showed appreciable improvement, ranging from preoperatively 45% to postoperatively 23%. The global AQS score showed a predominant improvement ranging from 36% to 70% followed by radicular pain subscore which ranged from 28% to 72% along with lower backache subscore which increased from 31% to 61%, while the neuro-ischemic subscore showed a slight rise from 48% to 80%. All of the above-mentioned improvements were statistically significant, i.e., P < 0.001. The major complications were noted to be neurological deficits in 4.9%, instrumental trauma in 3.6%, and deep SSIs in 0.5% of cases, which was the least. In the meantime, superficial SSI, dural tears, and systemic complications were some of the few minor problems faced postoperatively, but no life-threatening complications or associated loss of life relevant to the present study was recorded.[19] Similarly, in our study, we found a significant proportion of the cases having listhesis at L4–L5 level. Further, there was significant improvement in VAS and ODI score which were consistent with this study. However, isthmic listhesis cases were not considered in this study.

Omidi-Kashani et al. evaluated the end results of surgeries in patients with a mean age group of 58.3 ± 3.5 years affected with degenerative spondylolisthesis. 37 females and only 8 males participated in this study contributing to 82.2% and 17.8%, respectively. The number of cases observed in different levels was 35 cases in L4–L5, 3 cases each in L5–S1, L3–L4, and L3–L4–L5 along with 1 case each in L2–L3 and L4–L5–S1 contributing to 75.5%, 6.7%, 6.7%, 6.7%, 2.2%, and 2.2%, respectively. The preoperative VAS score improved from 8.8 to 2.1 postoperatively. The preoperative ODI score improved from 71.6 preoperatively to 21.3 postoperatively. Postoperatively, two cases of superficial infections accounting for 4.4% along with one case of implant failure were noted, but no major complications were reported during the surgery along with no neurological injury. No patient returned to the hospital for repeated surgical treatment.[20] The mean age and men-to-women ratio of this study are consistent with our present study. VAS and ODI score improvements are also in accordance with our study.

In a different study conducted by Inose et al. to assess the clinical outcomes of degenerative spondylolisthesis patients of mean age group 61.2 ± 6.7 years (65% females) who underwent decompression over a long time ago. Here, 41% of these patients observed instability. Out of those treated with fusion, 42% had instability and 40% of the patients treated with stabilization alone had instability. The VAS score for low backache improved postoperatively with statistical significance (P < 0.05). They also found that JOA score improved postoperatively with statistical significance.[21] Similarly, in our study, there was significant improvement in the postoperative JOA score. However, this study has not considered high-grade listhesis and isthmic listhesis in their analysis.

Dantas et al. looked upon the outcomes of patients managed with posterolateral fusion (PLF) and posterior lumbar interbody fusion (PLIF) both in association with pedicle screws for lumbar spondylolisthesis. They observed that 33 (55.5%) of the patients were female while 27 (45.5%) of the patients were male. 17 males and 13 females of mean age 52.4 years were treated with PLF, whereas 20 females and 10 males of mean age 47.6 years were managed with PLIF. They observed clinically that 58 cases had lower backache (96.6%), 56 cases had radicular pain (93.3%), 30 had neurogenic claudication (50%), and 24 had neurological deficits (40%). Out of the patients treated with PLF, 18 patients (60%) had significant increase in functional outcome with no backache. 10 patients showed partial functional recovery with backache and lower limb pain and 2 had no improvement. At the same time, from those managed with PLIF, 25 patients showed significant functional improvement along with no backache. Four patients showed partial functional recovery while one had no improvement. Oswestry mean preoperative score was 28.5, while Oswestry mean postoperative score was 18.6; this indicates that 73% of the patients were moderately disabled before the surgery, and after the operation, they showed significant improvement with 70% of them reporting with minimum to no disability.[22] Similar to our study, patients managed with surgical decompression and spinal fusion had significant functional improvement.

Audat et al. studied the clinical and radiological outcomes in patients who underwent PLF, PLIF, and transforaminal lumbar interbody fusion (TLIF) techniques for lumbar spondylolisthesis. They observed that among 27 patients treated with PLIF technique, the men-to-women ratio was 6:21 with most people having mean age of 50.6 years, whereas among the 17 who underwent PLF technique, the men-to-women ratio was 7:10 with most people having mean age of 54.2 years. The TLIF technique was used on another 37 patients having mean age of 44.8 years with the men-to-women ratio of 14:43. They observed that the symptomatic time period varied from 3 weeks to 29 years (mean 6.78 years) in patients treated with PLIF technique, whereas those managed by PLF and TLIF techniques ranged from 2 to 24 years (mean 7.8 years) and 1 month to 18 years (mean 4.6 years), respectively. In the meanwhile, all patients managed with PLF and PLIF had backache, sciatica, and neurogenic claudication (100%). Among those managed by PLF, 15 had sensory disturbance, i.e., 88.2%, 9 had muscle weakness, i.e., 12.67%, and only one had urinary incontinence, i.e., 0.05%. Moreover, among those managed with PLIF, 15 had sensory disturbance, i.e., 55.5%, while muscle weakness was seen in 13 patients, i.e., 48.1%. Only a single case (0.037%) that was managed with PLIF had urinary incontinence. 37 patients (100%) were treated with TLIF technique, and all of them showed backache, sciatica, and neurogenic claudication. Of these 29 (78.37%) had sensory deficits and 19 patients (51.35%) had muscle weakness. Complications were seen among 18.1% of patients.[23] The demographic profile of the cases in this study was similar to our study with significant functional improvement in the decompression and fusion group in both studies.[24],[25],[26],[27],[28],[29]


  Conclusion Top


Surgical decompression and spinal fusion either transforaminal interbody fusion or PLIF has good clinical outcomes in degenerative and isthmic spondylolisthesis along with remarkable improvement in the functional outcomes of patients managed by this procedure.

Limitation

  • Longer follow-up period is required for appreciating fusion radiologically
  • A larger study population is required
  • Although an effective technique, it has certain complications such as postoperative neurodeficit, surgical site infections, and pseudarthrosis.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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  In this article
Abstract
Introduction
Methods
Results
Discussion
Conclusion
References
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