Original ArticleIatrogenic Spondylolisthesis Following Open Lumbar Laminectomy: Case Series and Review of the Literature
Introduction
Laminectomy is a common procedure used to treat symptomatic degenerative lumbar stenosis. With proper patient selection and adequate decompression, the procedure is associated with relatively high patient satisfaction and good clinical outcomes.1, 2, 3 Surgical intervention effectively decompresses the central canal and lateral recesses to improve common stenotic symptoms such as neurogenic claudication and radiculopathy. However, in a few patients, laminectomy can alter normal spinal segment biomechanics and lead to iatrogenic instability and postoperative iatrogenic spondylolisthesis.4
Postoperative iatrogenic instability has been reported throughout the spine, including cervical kyphosis after laminectomies, thoracic instability after laminoforaminotomy-facet resections, and adjacent segment disease after spinal fusion.5, 6 This iatrogenic instability significantly impacts clinical outcomes and increases the risk for revision surgery.7 As increasing attention turns to long-term outcomes of patients after spinal procedures, it is important to assess the effects of iatrogenic instability in lumbar laminectomy, which is one of the most common spine procedures.7 First described in 1976,8 iatrogenic spondylolisthesis is radiographically defined as the translational motion of a spinal segment over an adjacent segment at the level of a previous decompression.9 It manifests most commonly at the L4-L5 level,10 and new or recurrent clinical symptoms require reoperation to stabilize any slipped segments.1, 11 Although preoperative and postoperative instability has been shown to be associated,12 there is little information on patients who do not initially present with signs of instability but still develop postoperative spondylolisthesis.
In this study, we report our experience with iatrogenic spondylolisthesis after open laminectomy. Often, patients with pre-existing spondylolisthesis are offered open decompression, distraction reduction, and fusion to mitigate their increased risk for postoperative instability.13 This case series specifically explores how patients without pre-existing instability can still develop postoperative spondylolisthesis. A systematic literature review was also performed to analyze the outcomes of iatrogenic spondylolisthesis after open laminectomy.
Section snippets
Case Series
This study received institutional review board approval. Because this study was descriptive in nature, informed patient consent was not required. Medical records were reviewed for all neurosurgical patients at a single institution undergoing first-time, bilateral 1-, 2-, 3-, and 4-level lumbar open laminectomies for degenerative spinal disease over an 18-year period. Patients undergoing surgery for tumors, trauma, or infection were excluded. To specifically examine patients without pre-existing
Case Series
Criteria for the final analysis were met by 105 patients. No patients were unstable before the index open laminectomy based on flexion-extension dynamic imaging. Review of imaging demonstrated that most of the 10 patients who developed subsequent iatrogenic spondylolisthesis had mild facet arthropathy (7 of 10), whereas 1 patient had moderate arthropathy, and 2 had no arthropathy. As their index operation, the 105 patients without pre-existing spondylolisthesis had open bilateral laminectomies
Discussion
Decompressive laminectomy is the gold standard for lumbar spinal stenosis and is associated with improved long-term outcomes.36 However, in a few patients, open laminectomy can compromise spinal integrity and lead to iatrogenic spondylolisthesis.37, 38 A review of the literature shows iatrogenic spondylolisthesis rates of 1.6%–32% (Table 2).8, 13, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 Reported factors that contribute to this complication vary widely owing to
Conclusions
Patients who develop postlaminectomy spondylolisthesis who did not have pre-existing lumbar instability make up a small but important subset of patients undergoing decompressive lumbar surgery. Studies indicate that the rate of postlaminectomy spondylolisthesis requiring fusion may range from 1.6% to 32%, and our case series had a congruent rate of 9.5% over a period of 32.6 ± 19.9 months. Multiple factors have been evaluated and implicated as potential contributors to this complication.
References (54)
- et al.
Iatrogenic spinal instability: cervical and thoracic spine
Semin Spine Surg
(2013) - et al.
Lumbar iatrogenic spinal instability
Semin Spine Surg
(2013) - et al.
Computer-assisted measurement of lumbar spine radiographs
Acad Radiol
(1997) - et al.
Long-term evaluation of decompressive surgery for degenerative lumbar stenosis
J Neurosurg
(1992) Lumbar spinal stenosis: postoperative results in terms of preoperative posture-related pain
J Neurosurg
(1990)- et al.
Analysis of operated cases with lumbar spinal stenosis
Acta Orthop Scand
(1981) New concepts on the pathogenesis and classification of spondylolisthesis
Spine (Phila Pa 1976)
(2005)- et al.
Cost per quality-adjusted life year gained of revision neural decompression and instrumented fusion for same-level recurrent lumbar stenosis: defining the value of surgical intervention
J Neurosurg Spine
(2012) - et al.
Spondylolisthesis after extensive lumbar laminectomy
J Bone Joint Surg Am
(1976) - et al.
MR imaging of lumbar spondylolysis: the importance of ancillary observations
AJR Am J Roentgenol
(1997)
Postoperative spondylolisthesis at L4-5: the role of facet joint morphology
Spine (Phila Pa 1976)
Iatrogenic spondylolysis leading to contralateral pedicular stress fracture and unstable spondylolisthesis: a case report
Spine (Phila Pa 1976)
Iatrogenic spondylolisthesis following laminectomy for degenerative lumbar stenosis: systematic review and current concepts
Neurosurg Focus
Prospective outcomes evaluation after decompression with or without instrumented fusion for lumbar stenosis and degenerative Grade I spondylolisthesis
J Neurosurg Spine
Degenerative lumbar intervertebral instability: what is it and how does imaging contribute?
Skeletal Radiol
Lumbosacral segmental motion in normal individuals: have we been measuring instability properly?
Spine (Phila Pa 1976)
Spondylolisthesis as an etiologic factor in backache
J Am Med Assoc
Correlation between disc height narrowing and low-back pain
Spine (Phila Pa 1976)
Spondylolisthesis after multiple bilateral laminectomies and facetectomies for lumbar spondylosis
J Neurosurg
Lumbar spinal instability (olisthesis) after extensive posterior spinal decompression
Spine (Phila Pa 1976)
Preoperative and postoperative instability in lumbar spinal stenosis
Spine (Phila Pa 1976)
Postoperative spondylolisthesis
Clin Orthop Relat Res
Postoperative lumbar spinal instability occurring or progressing secondary to laminectomy
Spine (Phila Pa 1976)
Spondylolysis after posterior decompression of the lumbar spine: 35 patients followed for 3-9 years
Acta Orthop Scand
Clinical outcomes and radiological instability following decompressive lumbar laminectomy for degenerative spinal stenosis: a comparison of patients undergoing concomitant arthrodesis versus decompression alone
J Neurosurg
Quantitative outcome and radiographic comparisons between laminectomy and laminotomy in the treatment of acquired lumbar stenosis
Neurosurgery
Minimum 10-year outcome of decompressive laminectomy for degenerative lumbar spinal stenosis
Spine (Phila Pa 1976)
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2022, World NeurosurgeryCitation Excerpt :Although traditional open laminectomy decompression can obtain better decompression space, it also brings many problems. Some studies have shown that after laminectomy, patients have a higher incidence of iatrogenic instability than after minimally invasive decompression.9-11 In comparison to decompression surgery alone, in patients who have lumbar spinal stenosis with or without degenerative spondylolisthesis, fusion surgeries have shown no significant advantage in terms of clinical outcomes in the medium and long term.12
Treatment of one-level degenerative lumbar spondylolisthesis with severe stenosis by oblique lateral interbody fusion: Clinical and radiological results after a minimal 1-year follow-up
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Conflict of interest statement: D. Sciubba has consulting relationships with Medtronic, Depuy Synthes, Stryker, NuVasive, and K2M. The remaining authors have no conflicts to report.
Seba Ramhmdani and Yuanxuan Xia are co–first authors.