Elsevier

The Spine Journal

Volume 19, Issue 3, March 2019, Pages 501-508
The Spine Journal

Clinical Study
Long-term outcome after spinal fusion for isthmic spondylolisthesis in adults

https://doi.org/10.1016/j.spinee.2018.08.008Get rights and content

Abstract

BACKGROUND CONTEXT

Data on the long-term outcome after fusion for isthmic spondylolisthesis are scarce.

PURPOSE

To study patient-reported outcomes and adjacent segment degeneration (ASD) after fusion for isthmic spondylolisthesis and to compare patient-reported outcomes with a control group.

STUDY DESIGN/SETTING

A prospective study including a cross-sectional control group.

PATIENT SAMPLE

Patients with isthmic spondylolisthesis underwent posterior lumbar interbody fusion (PLIF) (n=86) or posterolateral fusion (PLF) (n=77). Patient-reported outcome data were available for 73 patients in the PLIF group and 71 in the PLF group at a mean of 11 (range 5–16) years after baseline. Seventy-seven patients in the PLIF group and 54 in the PLF group had radiographs at a mean of 14 (range 9–19) years after baseline. One hundred thirty-six randomly selected persons from the population served as controls for the patient-reported outcomes.

OUTCOME MEASURES

Patient-reported outcomes include the following: global outcome, Oswestry Disability Index, Disability Rating Index, and Short Form 36. The ASD was determined from radiographs using the University of California Los Angeles (UCLA) grading scale.

METHODS

: The chi-square test or analysis of covariance (ANCOVA) was used for group comparisons. The ANCOVA was adjusted for follow-up time, smoking, Meyerding slippage grade, teetotaler (yes/no) and, if available, the baseline level of the dependent variable.

RESULTS

There were no significant patient-reported outcome differences between the PLIF group and the PLF group. The prevalence of ASD was 42% (32/77) in the PLIF group and 26% (14/54) in the PLF group (p=.98). The patient-reported outcome data indicated lower physical function and more pain in individuals with surgically treated isthmic spondylolisthesis compared to the controls.

CONCLUSIONS

PLIF and PLF groups had similar long-term patient-reported and radiological outcomes. Individuals with isthmic spondylolisthesis have lower physical function and more pain several years after surgery when compared to the general population.

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.

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    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.

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