Clinical StudyLong-term outcome after spinal fusion for isthmic spondylolisthesis in adults
Introduction
Isthmic spondylolisthesis is most commonly asymptomatic. The majority of cases are diagnosed due to incidental findings 1, 2. Approximately 25% develop symptoms in adulthood 2, 3, 4. Resolution of pain occurs in approximately 70% after nonoperative therapies, leaving 30% to surgical intervention [5]. Surgical treatment has better outcomes than continued nonoperative treatment in such cases [6], even though the current long-term evidence is derived from only one randomized controlled trial [7]. Decompression and fusion is a common procedure for managing this disorder and several surgical techniques for spinal fusion in isthmic spondylolisthesis are available, but at present there is no gold standard technique 7, 8, 9.
Interbody fusion has biomechanical advantages compared to posterolateral fusion (PLF) due to the anterior column support, indirect foraminal decompression, restoration of lordosis, and reduction of the slip via ligamentotaxis [10]. Studies have failed to show superior outcomes after interbody fusion surgery when compared to less complex techniques 9, 11, 12. Based on Swedish spine registry data, there was no difference in outcome between different surgical fusion techniques at a mean of 6.9 years, but the risk of additional surgery was 2 to 4 times higher for instrumented fusions compared to noninstrumented fusion [13].
Spinal fusion irreversibly alters the normal biomechanics of the spine and eliminates motion at the fused segment, causing an increased mechanical stress at the adjacent segments 14, 15, 16, 17. Adjacent segment degeneration (ASD), the degenerative changes that develop in the mobile segments adjacent to a spinal fusion, can be a potential long-term complication after lumbar fusion [18]. The reported incidence of ASD varies from 5% to 27% depending on the definition of ASD 19, 20, 21, 22, 23, 24. The radiographic incidence of ASD is higher than the symptomatic incidence [18], whereas the latter can be a cause of revision surgery 25, 26.
It is still unclear if there is any radiological difference regarding the incidence of ASD between different surgical fusion techniques for isthmic spondylolisthesis. Also, long-term data concerning health-related quality of life of surgically treated isthmic spondylolisthesis are scarce. We tried to improve the knowledge base by comparing patients surgically treated with two different techniques for isthmic spondylolisthesis as well as the general population. We hypothesized that long-term patient-reported and radiological outcomes would not be dependent on surgical technique and that surgical treatment normalizes patients’ health-related quality of life.
Section snippets
Materials and methods
Study patients included the following: (i) those from follow-up of a prospective consecutive cohort enrolled between 1997 and 2003 who were treated with posterior lumbar interbody fusion (PLIF) [9], (ii) a historical cohort from a randomized controlled trial in which patients were enrolled between 1990 and 1995 and were treated with PLF with or without instrumentation 8, 24, and (iii) controls from the general population without known isthmic spondylolisthesis enrolled between 2014 and 2015.
For
Results
Baseline data for the patient cohorts are presented in Table 1.
Discussion
Our data indicate that the type of surgery for isthmic spondylolisthesis is unrelated to outcome. A superior long-term outcome for circumferential fusion compared to PLF has been reported from a randomized controlled trial including degenerative lumbar disorders, but also patients with isthmic spondylolisthesis. However, the subgroup of 43 patients with isthmic spondylolisthesis failed to show any difference in outcome in relation to the surgical technique [33]. A previous meta-analysis of
Conclusions
Despite the theoretical advantages of interbody fusion compared to PLF, no improvement of patient-reported or radiological outcome could be demonstrated. Anterior support in the treatment of adult isthmic spondylolisthesis is not necessary.
Acknowledgment
No funds were received for the conduction of this study.
References (40)
- et al.
The long-term effect of posterolateral fusion in adult isthmic spondylolisthesis: a randomized controlled study
Spine J
(2005) - et al.
Adjacent segment stenosis after lumbar fusion requiring second operation
Journal of orthopaedic science: official journal of the Japanese Orthopaedic Association
(2005) - et al.
Reoperation rate and risk factors of elective spinal surgery for degenerative spondylolisthesis: minimum 5-year follow-up
Spine J
(2015) - et al.
The Swedish SF-36 Health Survey–I. Evaluation of data quality, scaling assumptions, reliability and construct validity across general populations in Sweden
Social science & medicine
(1995) - et al.
The Swedish SF-36 Health Survey II. Evaluation of clinical validity: results from population studies of elderly and women in Gothenborg
Journal of clinical epidemiology
(1998) - et al.
The Swedish SF-36 Health Survey III. Evaluation of criterion-based validity: results from normative population
Journal of clinical epidemiology
(1998) - et al.
The Disability Rating Index: an instrument for the assessment of disability in clinical settings
Journal of clinical epidemiology
(1994) - et al.
Investigating the role of DNA damage in tobacco smoking-induced spine degeneration
Spine J
(2014) - et al.
Spondylolysis and spondylolisthesis in children and adolescents: I. Diagnosis, natural history, and nonsurgical management
J Am Acad Orthop Surg
(2006) Lumbar spondylolisthesis. Clinical syndrome and operative experience with Cloward's technique
Acta neurochirurgica
(1982)
Isthmic spondylolisthesis
Neurosurgical focus
What is the optimum fusion technique for adult isthmic spondylolisthesis–PLIF or PLF? A long-term prospective cohort comparison study
J Spinal Disord Tech
Nonoperative treatment for painful adolescent spondylolysis or spondylolisthesis
J Pediatr Orthop
Surgery versus conservative management in adult isthmic spondylolisthesis–a prospective randomized study: part 1
Spine (Phila Pa 1976)
Instrumented and Noninstrumented Posterolateral Fusion in Adult Spondylolisthesis: A Prospective Randomized Study: Part 2
Spine
Posterior Lumbar Interbody Fusion Versus Posterolateral Fusion in Adult Isthmic Spondylolisthesis
Spine
Biomechanical study on the effect of five different lumbar reconstruction techniques on adjacent-level intradiscal pressure and lamina strain
J Neurosurg Spine
Fusion for low-grade adult isthmic spondylolisthesis: a systematic review of the literature
European spine journal: official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society
Adult low-grade acquired spondylolytic spondylolisthesis: evaluation and management
Spine (Phila Pa 1976)
Outcomes of Posterolateral Fusion with and without Instrumentation and of Interbody Fusion for Isthmic Spondylolisthesis: A Prospective Study
The Journal of bone and joint surgery American volume
Cited by (19)
Reduction of adolescent grade IV L5–S1 spondylolisthesis with anterior joystick manipulation during a combined anterior and posterior surgical approach: A case report
2023, North American Spine Society JournalIsthmic spondylolisthesis in adults… A review of the current literature
2022, Journal of Clinical NeuroscienceCitation Excerpt :They found a higher fusion rate in patients undergoing PLIF, but no significant differences in clinical outcomes between the two fusion procedures were observed. In addition, a prospective study by Swedish authors demonstrated that PLIF and PLF had similar long-term radiological and patient-reported outcomes [61]. These findings were supported by a recent systematic review and meta-analysis that included 8 randomized controlled trials with a total of 616 patients (308 PLF, 308 PLIF) to compare between PLF and PLIF in the management of spondylolisthesis or lumbar spinal stenosis [62].
Is there a place for surgical repair in adults with spondylolysis or grade-I spondylolisthesis—a systematic review and treatment algorithm
2021, Spine JournalCitation Excerpt :Currently, fusion is the commonest surgical procedure in adults, with established clinical success [8–10]. However, a high incidence of radiological ASD has been reported in the long-term in adults undergoing fusion for spondylolisthesis [11,12]. We believe that there may be a place for lysis repair in a subgroup of adults with only spondylolysis or up to grade-I spondylolisthesis.
Impact of obesity on restoration of sagittal balance and clinical efficacy after posterior lumbar interbody fusion
2019, Journal of Clinical NeuroscienceCitation Excerpt :Posterior lumbar interbody fusion (PLIF) isan effective treatment for patients who suffer from lumbar back pain and sciatica neuralgia, caused by lumbar instability or lumbar disc herniation. With the combination of a pedicle screw and rod, degenerative levels can be immobilized steadily and the intervertebral disc can be restored [1]. However, more than surgical parameters including the position and size of cages, separate patient conditions may impact the surgical efficacy of PLIF.
Isthmic Lumbar Spondylolisthesis
2019, Neurosurgery Clinics of North AmericaCitation Excerpt :Interbody fusion adds additional surgical time and adds greater risk and cost to treatment. A prospective Swedish study comparing the long-term outcome after spinal fusion for isthmic spondylolisthesis of 765 patients followed for an average of 7 years showed no significant patient-reported and radiologic outcomes between patients undergoing PLIF and posterior lumbar fusion alone.28 Radiographic variables, such as slip grade and slip angle, which would likely influence the decision to perform interbody fusion were outside of the scope of this study.
FDA device/drug status: Not applicable.
Author disclosures: PE: Nothing to disclose. PE: Nothing to disclose. HL: Nothing to disclose. TBB: Grants: Swedish Research Council (G, 2013-2016; E, 2018). Fellowship Support: Medtronic (D, Paid directly to institution). PG: Nothing to disclose. HM: Nothing to disclose.
- †
These authors contributed equally.