Elsevier

Clinical Neurology and Neurosurgery

Volume 138, November 2015, Pages 117-123
Clinical Neurology and Neurosurgery

Posterolateral fusion with interbody for lumbar spondylolisthesis is associated with less repeat surgery than posterolateral fusion alone

https://doi.org/10.1016/j.clineuro.2015.08.014Get rights and content

Highlights

  • Spondylolisthesis improved by 13% after PLF+PLIF/TLIF vs 5% after PLF (p < 0.001).

  • Interbody fusions were less likely to undergo reoperation compared to non-interbody.

  • Non-interbody fusion was strongest reoperation predictor for degenerative disease.

Abstract

Objective

Posterior or transforaminal lumbar interbody fusions (PLIF/TLIF) may improve the outcomes in patients with lumbar spondylolisthesis. This study aims to compare outcomes after posterolateral fusion (PLF) only versus PLF with interbody fusion (PLF + PLIF/TLIF) in patients with spondylolisthesis.

Methods

We retrospectively reviewed103 patients who underwent first-time instrumented lumbar fusions for degenerative or isthmic spondylolisthesis. Anterior techniques and multilevel interbody fusions were excluded. All patients were followed for at least 2 years postoperatively. Clinical outcomes including back pain, radiculopathy, weakness, sensory deficits, and loss of bowel/bladder function were ascertained from clinic notes. Radiographic measures were calculated with Tillard percentage of spondylolisthesis. Reoperation for progression of degenerative disease, a primary endpoint, was indicated for all patients with (1) persistent or new-onset neurological symptoms; and (2) radiographic imaging that correlated with clinical presentation.

Results

Of the 103 patients, 56.31% were managed with PLF and 43.69% with PLF + PLIF/TLIF. On radiographic studies, spondylolisthesis improved by a mean of 13.06% after PLF + PLIF/TLIF versus 5.67% after PLF (p < 0.001). In comparison to PLF + PLIF/TLIF, patients undergoing PLF experienced higher rates of postoperative improvement in back pain, sensory deficits, motor weakness, radiculopathy, and bowel/bladder difficulty; however, these differences did not reach statistical significance. The PLF cohort had a significantly higher incidence of reoperation (p = 0.011) and pseudoarthrosis/instrumentation failure (p = 0.043). In the logistical analyses, non-interbody fusion was the strongest predictor of reoperation for progression of degenerative disease.

Conclusion

Compared to PLF only, PLF + PLIF/TLIF were statistically significantly associated with a greater correction of spondylolisthesis. Patients with interbody fusions were less likely to undergo reoperation for degenerative disease progression compared to non-interbody fusions. However, greater listhesis correction and decreased reoperation in the PLF + PLIF/TLIF cohort should be weighed with favorable clinical outcomes in the PLF cohort.

Introduction

Spondylolisthesis is most commonly due to progressive vertebral body malalignment in the lumbar spine. The degenerative and isthmic types of spondylolisthesis account for 90% of all vertebral body slips [1]. The condition affects 20.7% of the general population aged 40–80 years [2], with only a portion of clinically symptomatic patients requiring operative management. Posterolateral fusion (PLF) plays an essential role in not only stabilizing the lumbar spine but also preventing the progression of the listhesis [3], [4]. Some authors argue that stopping disease progression is insufficient, and surgeons should also correct the spinal mal-alignment. In a clinical study on spondylotic spondylolisthesis, Suk et al argued that a posterior decompression followed by PLF caused a large gap at the level of the spondylolisthesis [5]. Suk et al. proposed a two-folded solution. First, the anterior column should be supported with an interbody graft at the level of the spondylolisthesis. Second, the listhesis should be actively reduced intraoperatively, thus narrowing the gap and reducing the bending motion over the interbody graft.

Despite these alleged benefits, physicians have long debated the role of interbody fusions since the posterior lumbar interbody fusion (PLIF) operation was first described by Cloward in 1943, and later modified with a transforaminal approach (TLIF) [6]. In response to the conflicting data in the literature, we compare PLF to PLF + PLIF/TLIF for the management of chronic spondylolisthesis. The objective of this study is to correlate radiographic findings with clinical measures, specifically long-term clinical outcomes, in interbody versus non-interbody fusions.

Section snippets

Materials and methods

Following institutional IRB approval (NA_00038491), we retrospectively reviewed patient records, operative notes, and radiographic images of all patients undergoing first-time posterolateral instrumented fusion of the lumbar spine at a single institution. Patients were recruited between January 1, 2004 and December 30, 2010. All operations were performed by one of 7 full-time neurosurgeons. All patients were managed for symptomatic degenerative or isthmic spondylolisthesis. All patients were

Results

We found 841 patients with degenerative spinal disease who underwent first-time, posterior instrumented fusions of the lumbar spine. While the patient population did have evidence of vertebral slippage, 103 patients (with follow up ≥ 2 years) underwent operations to specifically address symptomatic spondylolisthesis. Of the 103 surgical cases in the study population, 58 patients (56.31%) underwent PLF while 45 cases (43.69%) included a posterior or transforaminal interbody fusion (PLF + 

Discussion

The role of posterior and transforaminal interbody fusion has been strongly debated in the literature. In 2014 Journal of Neurosurgery Guideline Update for the Performance of Fusion Procedures for Degenerative Disease of the Lumbar Spine, Mummaneni et al. performed a literature review on interbody techniques in lumbar fusion. The authors published Grade B recommendations that interbody fusions may enhance the fusion rate, which, however, does not consistently translate to improved clinical

Conclusion

In our series of 103 patients, we correlate radiographic findings to clinical outcomes in patients undergoing PLF versus PLF plus interbody fusion in patients with degenerative or isthmic. Radiographic analysis revealed a statistically significantly greater improvement in spondylolisthesis following an interbody fusion. In comparison to PLF + PLIF/TLIF, patients undergoing PLF experienced higher rates of postoperative symptomatic improvements. However, the PLF cohort had a statistically

Conflict of Interest and Source of Funding

The authors have neither received funding nor report any conflicts of interests related to the set clinical study and composition of this manuscript. General disclosures (unrelated to this manuscript) include:

Timothy Witham is the recipient of a research grant from Eli Lilly and Company.

Daniel Sciubba is the recipient of a research grant from Depuy Spine. He has consulting relationships with Medtronic, Nuvasiv, Globus, and Depuy.

Ali Bydon is the recipient of a research grant from Depuy Spine.

References (24)

  • R.B. Cloward

    Spondylolisthesis: treatment by laminectomy and posterior interbody fusion

    Clin. Orthop. Relat. Res.

    (1981)
  • L. Kalichman et al.

    Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population

    Spine

    (2009)
  • R. Louis

    Fusion of the lumbar and sacral spine by internal fixation with screw plates

    Clin. Orthop. Relat. Res.

    (1986)
  • H.H. Matthiass et al.

    The surgical reduction of spondylolisthesis

    Clin. Orthop. Relat. Res.

    (1986)
  • S.I. Suk et al.

    Adding posterior lumbar interbody fusion to pedicle screw fixation and posterolateral fusion after decompression in spondylolytic spondylolisthesis

    Spine

    (1997)
  • R.B. Cloward

    The treatment of ruptured lumbar intervertebral discs by vertebral body fusion. I. Indications, operative technique, after care

    J. Neurosurg.

    (1953)
  • W.A. Abdu et al.

    Degenerative spondylolisthesis: does fusion method influence outcome? Four-year results of the spine patient outcomes research trial

    Spine

    (2009)
  • A. Pearson et al.

    Degenerative spondylolisthesis versus spinal stenosis: does a slip matter? Comparison of baseline characteristics and outcomes (SPORT)

    Spine

    (2010)
  • T.S. Videbaek et al.

    Circumferential fusion improves outcome in comparison with instrumented posterolateral fusion: long-term results of a randomized clinical trial

    Spine

    (2006)
  • H. Akaike

    A new look at the statistical model identification

    IEEE T. AUTOMAT. CONTR. on

    (1974)
  • M.S. Pepe

    The Statistical Evaluation of Medical Tests for Classification and Prediction

    (2003)
  • D.W. Hosmer et al.

    Applied Logistic Regression

    (2004)
  • Cited by (0)

    1

    These authors contributed equally to this manuscript.

    View full text