Posterolateral fusion with interbody for lumbar spondylolisthesis is associated with less repeat surgery than posterolateral fusion alone
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.
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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.
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These authors contributed equally to this manuscript.