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Comparative Study Between Instrumented Posterolateral Fusion and Transforaminal Lumbar Interbody Fusion in Isthmic Spondylolisthesis

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Comparative Study Between Instrumented Posterolateral Fusion and Transforaminal Lumbar Interbody Fusion in Isthmic Spondylolisthesis AL-AZHAR ASSIUT MEDICAL JOURNAL AAMJ ,VOL 13 , NO 3 , JULY 2015 – suppl 1 COMPARATIVE STUDY BETWEEN INSTRUMENTED POSTEROLATERAL FUSION AND TRANSFORAMINAL LUMBAR INTERBODY FUSION IN ISTHMIC SPONDYLOLISTHESIS Samy Moussa Selim1, Reda Ali Shetta2 and Samer Ibrahim Alajouz3. 1- Lecturer of neurosurgery faculty of medicine for girls, Al-Azhar university, Cairo, Egypt. 2- Consultant of orthopedic, AlAhrar hospital, Zagazig, Egypt. 3- Consultant of orthopedic, AlAhsa hospital, KSA. ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ ABSTRACT Background: Spondylolisthesis refers to slippage of one vertebra over the other, which may be caused by a variety of reasons such as degenerative, trauma, and isthmic. Surgical management forms the mainstay of treatment to prevent further slip and worsening. However, there is no consensus regarding the best surgical option to treat these patients. This study compares instrumented posterolateral fusion (PLF) and transforaminal lumbar interbody fusion (TLIF) in patients with isthmic spondylolisthesis and analysis the outcome with respect to clinical and radiological outcome. Materials and Methods: Twenty-six patients operated for spondylolisthesis by instrumented posterolateral or transforaminal fusion between October, 2012, and March, 2014 were included in this retrospective study. They were followed up for 8 to 48 months. Fourteen cases were PLF and twelve cases were TLIF. The patients were evaluated clinically and radiologically at preoperative, and at 1, 6, 12 and 24 months postoperatively and median value of postoperative results was taken to compare it with preoperative data. Results: Both procedures significantly improved the Oswestry Disability Index (ODI) and visual analog scale (VAS) scores; however, the postoperative ODI and VAS scores were unaffected by the procedure type. Postoperative disc heights and percent changes in disc heights did not change by operation type; however, the percent change in the foramen areas was significantly greater in the TLIF group. The addition of TLIF to the PLF procedure resulted in significantly longer operating time and more intraoperative blood loss. Cerebrospinal fluid fistula was the only major complication noted. The radiologic fusion rates were similar between both study groups. Conclusions: Both PLF and TLIF procedures were effective in ameliorating the symptoms of isthmic spondylolisthesis. Although some radiologic parameters favor TLIF, this was not reflected in the clinical outcomes. Key words: Posterolateral fusion, Transformational lumbar interbody fusion, isthmic spondylolisthesis. Abbreviation: ODI = Oswestry Disability Index, PLF = Posterolateral fusion, PLIF = Posterior lumbar interbody fusion, TLIF = Transforaminal lumbar interbody fusion, VAS = Visual Analogue Scale. ALIF= anterior lumbar interbody fusion. INTRODUCTION vertebrae over the subjacent vertebrae as Spondylolisthesis, which typically occurs the initial mechanisms of instability (2). in the lumbosacral region, is a relatively Despite regional involvement, the common entity in clinical practice and subluxation of the segmental lumbar may one of the most common causes of influence the entire biomechanical chronic low back pain (1). It is balance of the spine (3). Among the 5 characterized by the slippage of upper subtypes of spondylolisthesis, isthmic 431 | P a g e Samy Moussa Selim et al AAMJ ,VOL 13 , NO 3 , JULY 2015 – suppl 1 spondylolisthesis is named for the between October, 2012, and March, 2014 osseous discontinuity of the vertebral arch were included in this retrospective study. at the pars interarticularis (spondylolysis) The follow up period ranged from 8 to 48 (2). Frequently demonstrated at the L5/S1 months. Fourteen cases were of level, isthmic spondylolisthesis generally instrumented posterolateral fusion (PLF) is considered to be associated with the and twelve cases were of transforaminal stress or fatigue fracture of pars lumbar interbody fusion (TLIF). The interarticularis, with an approximate patients fulfilling the inclusion and incidence of 6% in adults (4,5). Surgical exclusion criteria were included in the interventions are regarded as essential for study. Inclusion criteria were (1) People symptomatic patients with isthmic of either sex who are 18–70 years of age spondylolisthesis. Various fusion (2) X-ray and magnetic resonance techniques that incorporate different imaging (MRI) proven isthmic approaches, vertebral fixation, and fusion spondylolisthesis (3) the grade of materials have been developed and used spondylolisthesis was single level and widely, such as posterolateral fusion, low grade (grade I and II) (4) Consented posterior lumbar fusion, posterior lumbar for the surgical procedures (TLIF and interbody fusion (PLIF), anterior lumbar instrumented PLF) (5) Appeared for interbody fusion, lateral lumbar interbody periodic follow-ups (6) Consented to fusion, and transforaminal lumbar include themselves in the study. The interbody fusion (TLIF) (6). exclusion criteria were (1) Patients who However, there is no consensus regarding have X-ray and MRI proven which form of fusion surgery is the best spondylolisthesis Grade III and IV (2) to treat this problem (7). Various degenerative spondylolisthesis (3) randomized controlled trials (RCTs) have Pregnant women (4) Unsound mind been performed which show no (cannot fill up the questionnaires) (5) Not significant difference in outcomes consented to the study (6) Previous back between instrumented and surgery (7) Previous fractures of the uninstrumented fusion especially in the spine. short term (8,9). However, there is an Diagnosis and decision for surgery were increasing trend toward interbody fusion. determined after a thorough medical This study has been designed to compare history and detailed physical examination. the outcomes between TLIF versus All patients received preoperative instrumented posterolateral fusion (PLF) conservative therapy comprising bed rest, in patients with isthmic spondylolisthesis. nonsteroidal anti-inflammatory drugs, and This study compares instrumented PLF physical therapy for at least 8 weeks. and TLIF in patients with isthmic The patients were worked up for spondylolisthesis and analyzes the anesthetic fitness and all comorbidities outcome with respect to functional were appropriately treated. outcome, pain, fusion rate, adequacy of OPERATIVE PROCEDURE medial facetectomy for decompression, Under general anesthesia, with the patient and complications. in prone position, a standard posterior MATERIALS AND METHODS midline incision was made. Levels were Twenty-six patients operated for ishtmic confirmed using fluoroscopy. Patient is spondylolisthesis by instrumented positioned prone recreating lumbar posterolateral or transforaminal fusion lordosis. Polyaxial pedicle screws 432 | P a g e AL-AZHAR ASSIUT MEDICAL JOURNAL AAMJ ,VOL 13 , NO 3 , JULY 2015 – suppl 1 inserted. This helped in achieving Plain radiographs and computed reduction. No additional reduction tomography were used to evaluate the maneuvers were used. radiologic fusion according to the Lenke In the instrumented PLF group, inferior and Bridwell classification. The OsiriX facet of the superior vertebra was DICOM Viewer was used for radiologic removed bilaterally. Superior articular measurements. Segmental lordosis facet of the inferior vertebral body (relevant to the operated levels) and the preserved and surface curetted up to total lumbar lordosis angles, bleeding bone to make a good bed for intervertebral disc heights, and foramen fusion. Bone grafting was done in the areas were measured as radiologic triangle between superior articular facet, parameters. transverse process, and pars. Segmental and total lordosis Unilateral facetectomy was performed for measurements were conducted using the the TLIF group. Discectomy was done. Cobb method. Intervertebral height was This was followed by preparation of end measured at the anterior, middle, and plates and measurement and insertion of a posterior ends of the intervertebral space TLIF cage packed with bone graft. Global in the midsagittal plane, and the average fusion was not performed. of these 3 measures was recorded. For instrumented PLF, local graft Because the facet joints were excised for harvested from the inferior articular cage insertion, the foramen areas in the process of the superior vertebra bilaterally TLIF group were measured on the along with bone taken from lamina while contralateral side of the operation. doing a foraminotomy was used. Measurements were performed in the For TLIF, bones were taken from oblique plane passing through the foraminotomy site with facetectomy and midpoint of the vertebral pedicle width. A removal of pars were utilized. No similar measurement was made in the deliberate attempt was made for reduction PLF group; however, the mean values of since the study included only low-grade the left and right foramen areas were listhesis. The reduction that was achieved recorded. during the procedure was accepted. Statistics Wounds were closed after securing Wizard 1.9.18 for MacOS was used for perfect hemostasis. statistical analysis. When samples did not Patients were mobilized as tolerated. show normal distribution, the Manne Back strengthening exercises were started Whitney U test was used for unpaired as early as second postoperative day. No data, and Wilcoxon signed-rank test was brace was used.
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