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Long-Term Outcome After Monosegmental L4/5 Stabilization

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Long-Term Outcome After Monosegmental L4/5 Stabilization View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Bern Open Repository and Information System (BORIS) PRIMARY RESEARCH Long-term Outcome After Monosegmental L4/5 Stabilization for Degenerative Spondylolisthesis With the Dynesys Device Sven Hoppe, MD,*w Othmar Schwarzenbach, MD,* Emin Aghayev, MD,z Harald Bonel, MD,y and Ulrich Berlemann, MD* results. The rate of secondary surgeries is comparable to other Study Design: Retrospective analysis of prospectively collected dorsal instrumentation devices. Residual range of motion in the clinical data. stabilized segment is reduced, and the rate of radiologic and Objective: To assess the long-term outcome of patients with symptomatic adjacent segment degeneration is low. Patient monosegmental L4/5 degenerative spondylolisthesis treated with satisfaction is high. Dynesys stabilization of symptomatic L4/5 the dynamic Dynesys device. degenerative spondylolisthesis is a possible alternative to other stabilization devices. Summary of Background Data: The Dynesys system has been used as a semirigid, lumbar dorsal pedicular stabilization device Key Words: monosegmental degenerative spondylolisthesis, since 1994. Good short-term results have been reported, but dynamic stabilization, long-term follow-up, Dynesys little is known about the long-term outcome after treatment for (Clin Spine Surg 2016;29:72–77) degenerative spondylolisthesis at the L4/5 level. Methods: A total of 39 consecutive patients with symptomatic degenerative lumbar spondylolisthesis at the L4/5 level were egenerative lumbar spondylolisthesis (DLS) is a treated with bilateral decompression and Dynesys in- Dcommon condition in elderly patients and a frequent strumentation. At a mean follow-up of 7.2 years (range, cause of spinal stenosis. DLS most commonly occurs at 5.0–11.2 y), they underwent clinical and radiographic evaluation the L4/5 level. Although most patients can be treated and quality of life assessment. conservatively, up to 15% may require surgical treatment Results: At final follow-up, back pain improved in 89% and leg because of refractory back and leg pain, spinal claudica- 1 pain improved in 86% of patients compared with preoperative tion, and/or radicular pain. Decompression of the spinal status. Eighty-three percent of patients reported global sub- stenosis may improve symptoms of claudication and 1,2 jective improvement. Ninety-two percent would undergo the radicular pain, and fusion is intended to prevent pro- 3 surgery again. Eight patients (21%) required further surgery gression of the sagittally unstable spondylolisthesis. The because of symptomatic adjacent segment disease (6 cases), late- combination of decompression and fusion shows a sig- 3 onset infection (1 case), and screw breakage (1 case). In 9 cases, nificantly better outcome than decompression alone. radiologic progression of spondylolisthesis at the operated seg- The Dynesys system (Zimmer, Winterthur, Swit- ment was found. Seventy-four percent of operated segments zerland) has been used as a semirigid stabilization device showed limited flexion-extension range of <4 degrees. Adjacent for the treatment of DLS since 1994. The pedicle screw– segment pathology, although without clinical correlation, was based system is intended to provide mobile stabilization, diagnosed at the L5/S1 (17.9%) and L3/4 (28.2%) segments. In controlling motion in all 3 planes. It is designed to restore 4 cases, asymptomatic screw loosening was observed. stability and treat painful degenerative conditions such as unstable degenerative disk disease and lumbar stenosis. Conclusions: Monosegmental Dynesys instrumentation of de- Indications for this device are local lumbar pain and/or generative spondylolisthesis at L4/5 shows good long-term radicular pain attributed to instability with or without accompanying neurological deficit. Dynesys is also de- signed to stop further progression of minor deformities Received for publication March 27, 2012; accepted October 5, 2012. frequently associated with spinal stenosis, including de- From the *Das Ru¨ ckenzentrum, Spinal Surgery, Thun; wDepartment of Orthopaedic Surgery, University of Bern, Inselspital; zMEM generative spondylolisthesis and early degenerative sco- 4,5 Research Center, Bern; and yDepartment of Radiology, University liosis. Biomechanical studies have shown that the of Bern, Inselspital, Bern, Switzerland. Dynesys system allows for a nearly physiological spinal The authors declare no conflict of interest. extension, whereas forward spinal flexion is comparable Reprints: Sven Hoppe, MD, Department of Orthopaedics and Trau- matology, University of Bern, Inselspital, Bern 3010, Switzerland to that achieved after implantation of a fusion device. (e-mail: [email protected]). With this implant, lateral side bending is diminished up to Copyright r 2012 Wolters Kluwer Health, Inc. All rights reserved. 40%, whereas rotation is not significantly reduced.6,7 72 | www.clinicalspinesurgery.com Clin Spine Surg Volume 29, Number 2, March 2016 Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved. Clin Spine Surg Volume 29, Number 2, March 2016 Degenerative Spondylolisthesis TABLE 1. Age, Sex, Reason For Reintervention and Resurgery, and Time After Index Surgery in n = 8 Cases Case Time After Index Number Age Sex Reason for Reintervention Surgery Surgery 1 69 F Spinal stenosis L2/3 with degenerative spondylolisthesis PLIF L2/3 9.4 Decompression L2/3 2 31 F Late-onset infection L4/5 right Partial implant removal 7.3 3 65 F Adjacent segment degeneration L3/4 with degenerative Reinstrumentation, Dynesys 6.4 spondylolisthesis extension L2-5 4 58 F Adjacent segment degeneration L5/S1 ALIF L5/S1 6 5 45 M Adjacent segment degeneration L5/S1 with protrusion ALIF L5/S1 3.5 6 61 F Adjacent segment degeneration L3/4 with protrusion Reinstrumentation, Dynesys 2.5 extension L2-5 7 33 F Adjacent segment degeneration L5/S1 ALIF L4/5 2.3 disk prosthesis L5/S1 8 39 F Pedicle screw breakage L5 left Prtial implant removal 1.4 ALIF indicates anterior lumbar interbody fusion; PLIF, posterior lumbar interbody fusion. In theory, the preservation of some motion at the in- indications to implantation and excluded from this study. strumented segment is intended to diminish adjacent The minimum follow-up period was set to be 4 years. segment degeneration. Short-term follow-up studies (up Of the 55 patients treated during this period, there to 2 y) showed similar results of Dynesys compared with were 41 women (74.5%) and 14 men (25.5%) with a mean conventional fusion techniques regarding clinical out- age at surgery of 60 years (range, 31–85 y). Thirty-nine come and perioperative and postoperative complica- patients (71%; 30 women, 9 men) with a mean age of 66 tions.5,8 However, long-term data are sparse. years (range, 40–91 y) were available for evaluation after This study presents a 7.2-year follow-up (range, a mean follow-up time of 7.2 years (range, 4.8–11.2 y). 5–11.2 y) of DLS at the L4/5 level, treated with decom- Sixteen patients (29%) were lost to follow-up. Twelve pression and Dynesys stabilization. (22%) had died, 2 (3.6%) could not be contacted, and 2 others (3.6%) refused a visit because of immobility un- related to spinal problems. The 2 patients unable to visit MATERIALS AND METHODS because of immobility reported over the telephone that Between 2000 and 2006, 55 patients were treated they had no back or leg pain, but were not included in our using a monosegmental Dynesys system for DLS at the follow-up. L4/5 level. Two experienced spine surgeons performed all surgeries using the same operative technique. All patients Clinical Outcome underwent decompression of bilateral recesses, under- At follow-up investigation, standard neurological cutting laminotomies, and instrumentation. and physiological examination was performed. The need Indication for implantation of the Dynesys device for pain medication was noted and any complications or was determined on the basis of the preoperative clinical additional operations directly related to the index surgery. and radiologic evaluation. The preoperative evaluation For patient-based outcome measurement, a questionnaire included standard radiographs [anteroposterior (AP) and described by Grob et al9 was used. The questionnaire lateral], magnetic resonance imaging, and neurological assesses (1) changes in back and leg symptoms after sur- and physical examination. Degenerative spondylolisthesis gery; (2) duration of improvement; (3) reoperations; (4) of >1 level or any prior lumbar surgery were contra- changes in work status; (5) quality of life and free-time TABLE 2. Questionnaire According to Grob and Colleagues Concerning Remaining Back and Leg Pain, Improvement of Free-time Activities, and General Quality of Life Back Pain (%) Leg Pain (%) Work Status (%) Free Time (%) Quality of Life (%) Much improved 42 40 29 37 34 Improved 47 47 53 47 50 No change 3 8 13 5 11 Worse 8 5 5 11 5 Surgery total Much improved 50 Improved 33 Helped a little 8 No change 3 Worse 5 Surgery again Yes 92 No 8 Copyright r 2012 Wolters Kluwer Health, Inc. All rights reserved. www.clinicalspinesurgery.com | 73 Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved. Hoppe et al Clin Spine Surg Volume 29, Number 2, March 2016 TABLE 3. Spine Tango Scores at the Final Follow-Up “Spine Tango” Scores Minimum Maximum Mean Median SD ODI score 0.00 82.00 17.50 12.00 18.80 EQ-5D 0.00 1.00 0.80 0.80 0.25 COMI 0.00 9.60 3.00 2.90 2.60 SF-36 physical functioning score 22.1 56.5 45.0 47.9 10.3 COMI indicates core outcome measures index; ODI, Oswestry Disability Index. activities; and (6) global outcome. The questionnaire operative radiograph with that from the most recent also asks the patient if they would undergo surgery again. follow-up. The Sim index quantifies the grade of spon- In addition, patients were evaluated with the “Spine dylolisthesis in the lateral lumbar radiograph. It is Tango” questionnaire, which includes the SF-36, calculated by dividing the length of the uncovered superior EQ-5D, Oswestry Disability index (ODI), and Core end plate of the caudal vertebral body by the full length of Outcome Measures Index.
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