Pedicle Screw Fixation with Decompression: The Ultimate Solution for Medically Intractable Spondylolistheses.

Objective: To know the surgical outcome of Pedicle screw fixation with decompression in patients of spondylolistheses with failed conservative treatment.

Methodology. This observational prospective study was performed in the department of Neurosurgery in MTI LRH Peshawar January 2017 to Jan 2020. Patients with lumbar Spondylolisthesis irrespective of age and gender discrimination were included after informed consent. All the patients were evaluated before surgery. The procedure was done in prone position under general anaesthesia. Pedicles screw fixation with decompression was done in all patients and TLIF or delta fixation was also done as needed. Patients data was documented at discharge and then in subsequent follow up visits. Plane x-ray or sometimes CT was done to assess the implant position and any sign of failure. The data was stored in computer and analysed by SPSS.

Results Out of total 44, there were24 (54.55%) male and 20 (45.45%) female patients. Age ranged from 16 to 72 years with a mean 43 years ± 9.48 SD. Most common presentation was back ache which was present in all patients 100 %(n=44) followed by claudication in which was present in 90.90% (n=39)patients. Radicular symptoms were present in 88.64% (n=40). Simple pedicle screw fixation and decompression was done in 25(56.82%) cases, TLIF in 15(34.09%) patients and delta fixation in 5(S11.36%) patients.Pain was main indication for surgery which was severe in 31 (70.45%), excruciating in 7 (15.90%) and moderate in 7 (15.90%). After surgery, there were 65.90 % (n=29) pain free patients. Ten patients (22.72%) had mild pain and 6 patients (13.64%) had moderate pain. There was wound infection in 2(4.54%) patients and implants failure was seen in one (2.27%) patient. One patient (2.27%) had incidental durotomy .

Conclusion Spondylolisthesis is a middle age disease with slight male preponderance . back pain is commonest presentation. Posterior fixation with or without interbody fusion yields good results.

Key word: Spondylolisthesis, posterior fixation and decompression, outcome

Received: July’2020                        Accepted: Sep’2020

INTRODUCTION

Spondylolisthesis is one common cause of low back pain1. It is more prevalent in the middle age people and elderly population. Spondylolistheses may or may not be symptomatic. However the asymptomatic patients are more common in elderly and female population2. The treatment of this condition may be surgical or non-surgical. In general the treatment begins with conservative measures like changes in life style, physical therapy, medication, weight reduction and epidural injection. In many patients the non-surgical treatments is effective and adequate3,4,5.

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Spondylolisthesis is a middle age disease with
slight male preponderance . back pain is commonest
presentation. Posterior fixation with or
without inter-body fusion yields good results.

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However if non-operative treatment fail, the operative treatment stands the ultimate option. Surgical options include spinal fixation and fusion. In some cases direct pars repair is done instead of spondylodesis.6 Some other options include Bucks fusion, Morscher Screw and hook Fixation7, sublaminar wiring (Scott’s Operation) , bone grafting without instrumentation ,Laminoplasty8 posterolateral lumbar fusion (PLF), posterior lumbar inter body fusion (PLIF)9, transforamina lumbar inter body fusion (TLIF)10, anterior and posterior combined fusion11. Other methods are transpedicular transdiscal transcorporial screw fixation (TPT DTC)12, delta fixation, extreme lumbar inter body fusion (XLIF), axial lumbar inter body fusion (AXIA- LIF), anterior lumbar inter body fusion (ALIF) and Vertebrectomy i.e. Gaine’s procedure13. The procedure of choice for Spondylolisthesis varies from patients to patient depending on age, etiology, grade of spondylolisthesis14.However In all these procedures proper decompression with fusion and not a complete reduction should be the objective15. However to achieve best result, one need to do proper patient selection and go for specific kind of procedure16. We conducted study on our patients who were operated for spondylolistheses to analyse our experience with posterior fixation with fusions in their management. of spondylolisthesis and the main aim was to study the efficacy of posterior pedicular screw rod system and postero-lateral fusion in terms of functional outcome, to study the complications associated with this treatment modality and to compare the efficacy and complications with the available literature.

MATERIAL METHODS

This observational prospective study was performed in the department of Neurosurgery in MTI LRH Peshawar January 2017 to Jan 2020.

Inclusion criteria: patients were included with lumbar Spondylolisthesis irrespective of age and gender discrimination. However patients who lost to follow up in the first 6 months were excluded. We took informed consent patients before making them part of our study. All the patients were thoroughly evaluated before surgery. Detailed history was taken and the necessary investigations were done including MRI and in some cases CT scan too. Pre operative antibiotics given to all patients. The procedure was done in prone position midline incision was given to all patients and generous necessary exposure upto bony landmarks was done. Screws were passed in all patients before laminectomy. After laminectomy dissectomy was performed if we would go for TLI. If reduction could be achieved without disscectomy the procedure would stopped without going for TLIF. Delta fixation was performed in high grade listhesis. We filled the cages with bone graft and the cortical surfaces of face joints were decorticated and bone graft was placed over it for fusion purpose. In some cases we did soft TLIF where instead of cage we merely put bone graft to prevent cage subsidence as in severely osteoporotic spine. Post operatively all patients were kept on parenteral analgesia unless their pain could adequately be controlled on oral analgesics. In all patients intravenous antibiotics were used for 5 days. Just before discharge and then in subsequent follow up plane x-ray or sometimes CT was done to assess the implant position and any sign of failure. Pain assessment was done at three months and six months using Graphic rating scale (GRS) as mild, moderate, severe and pain as bad as it could be (excruciating) .The data was stored in computer and analysed SPSS.

RESULTS

Total 44 patients qualified the inclusion criteria. There were24 (54.55%) male and 20 (45.45%) female. Age ranged from 16 to 72 years with a mean 43 years ± 9.48 SD. Most common presentation was back ache which was present in all patients 100% (n=44) followed by claudication in which was present in 90.90% (n=39) patients. Radicular symptoms were present in 88.64% (n=40). Various presentation are shown in table 1.

We did pedicle screw fixation and decompression in 25(56.82%) cases, TLIF in 15(34.09%) patients and delta fixation 5(S11.36%) patients.

Pain was main indication for surgery which was severe in 31 (70.45%%), excruciating in 7 (15.90%%) and moderate in 7 (15.90%%). After surgery, there were 65.90 % (n=29) pain free patients. Ten patients (22.72%) had mild pain and 6 patients (13.64%) had moderate pain.

No neurological deterioration was noted in our cases but there was infection in 2(4.54%) patients and implants failure was seen in one (2.27%) patient. One patient (2.27%) had incidental durotomy which went unnoticed at the time of surgery that resulted in post CSF leak.

DISCUSSION

There has been various treatment options for Spondylolisthesis depending upon the presentation, type and grade of listhesis. Certain types like of isthmic and degenerative Spondylolisthesis are initially treated conservatively treated17. Common indication for surgery is back pain and claudication affecting routine life with failed conservative treatment and neurological deficit18. Spondylolisthesis can occur commonly in 4th or 5th decade of life. In one national study the average age was 44 ± 10.4915. In the current study the average age is mean 43 years ± 9.48 SD. Hence the two study results are in keeping with each other. Spondylolistheses is slightly more in male population. Zeng ZL et all study shows a male to female ratio of 1.1:119. Similarly, Tahir M et all15 demonstrated more males 50 (53.19%), as compared to females i.e. 44 (46.80%). In our study the male to female ratio is in close range with above studies. However in some studies Women showed a higher incidence of degenerative spondylolisthesis compared to men, with a male-to-female ratio of 1:3, .Abdominal muscle function gets impaired in pregnancy, resulting in poor support from abdominal muscle to spinal mechanics in women20. Pasha et all14conducted a study in which he found that 64.44% patients were pain free after surgery and there were 11.11% patients who still had severe pain after surgery. Iin our study from the date we can see that 65.90 % patients are pain free after surgery. 13.64% patient had moderate pain while there is not a single patient having sever or excruciating pain after surgery. No neurological deterioration was noted in our cases but there was infection in 2(4.54%) patients and implants failure was seen in one (2.27%) patient. One patient (2.27%) had incidental durotomy which went unnoticed at the time of surgery that resulted in post CSF leak. Khan MZ etall16reported non-union (3.4%) and 2 (6.9%) early deep infections. This study has got limited number of patients as study population. Follow up period is just six month. In our society maintaining long follow up is logistically difficult. Pre and post op pain assessments were done by different doctors. Hence there can be a possibility of error in judgment. Likewise different surgeon performed these surgeries. Hence experience and expertise may affect the outcome. We recommend randomized clinical trials to provide evidence based results.

CONCLUSION

Spondylolisthesis is middle age disease with slight male preponderance. Back pain is commonest presentation. Posterior fixation with or without inter-body fusion yields good results.

1. Chaitanya M, Mittal A, Rallapalli R, Teja R, Prasad YS. “Surgical Management of Spondylolisthesis by Pedicular Screw Rod System and Postero-Lateral Fusion” Open Journal of Orthopedics, 2015, 5, 163-174.

2. Hammerberg KW. New concepts on the pathogenesis and classification of spondylolisthesis. Spine, 2005;30:S4-11.

3. Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008;17:327-35.

4. Sengupta DK, Herkowitz HN. Lumbar spinal stenosis. Treatment strategies and indications for surgery. Orthop Clin North Am. 2003;34:281-95.

5. Pearson AM, Lurie JD, Blood EA, Frymoyer JW, Braeutigam H, An H, et al. Spine patient outcomes research trial: radiographic predictors of clinical outcomes after operative or nonoperative treatment of degenerative spondylolisthesis. Spine 2008;33(25):2759–66.

6. Rajasekaran S, Subbiah M, Shetty AP. Direct repair of lumbar spondylolysis by Buck’s technique. Indian J Orthop 2011;45(2):136–40.

7. Debusscher F, Troussel S. Direct repair of defects in lumbar spondylolysis with a new pedicle screw hook fixation: clinical, functional and Ct-assessed study. Eur Spine J 2007;16(10):1650–8.

8. Kotil K, Akcetin M, Tari R, Ton T, Bilge T. Replacement of vertebral lamina (laminoplasty) in surgery for lumbar isthmic spondylolisthesis. A prospective clinical study. Turk Neurosurg 2009;19(2):113–20.

9. Kim DH, Jeong ST, Lee SS. Posterior lumbar interbody fusion using a unilateral single cage and a local morselized bone graft in the degenerative lumbar spine. Clin Orthop Surg 2009;1(4):214–21.

10. Hioki A, Miyamoto K, Hosoe H, Sugiyama S, Suzuki N, Shimizu K. Cantilever transforaminal lumbar interbody fusion for upper lumbar degenerative diseases (minimum 2 years follow up). Yonsei Med J 2011;52(2):314–21.

11. Lee DY,Lee SH, Maeng DH. Two-level anterior lumbar interbody fusion with percutaneous pedicle screw fixation: a minimum 3-year follow-up study. Neurol Med Chir (Tokyo) 2010;50(8):645– 50.

12. Zagra A, Giudici F, Minoia L, Corriero AS, Zagra L. Longterm results of pediculo-body fixation and posterolateral fusion for lumbar spondylolisthesis. Eur Spine J 2009;18:151–5.

13. Aunoble S, Hoste D, Donkersloot P, Liquois F, Basso Y, Le Huec JC. Video-assisted ALIF with cage and anterior plate fixation for L5–S1 spondylolisthesis. J Spinal Disord Tech 2006;19:471–6.

14. Pasha IF, Qureshi MA, Haider IZ, Malik AS, Qureshi MA, Tahir UB, “Surgical treatment in lumbar spondylolisthesis: experience with 45 patients” J Ayub Med Coll Abbottabad 2012;24(1) ,75-78.

15. Tahir M, Rehman L, Bokhari I, et al. Surgical Outcome of Decompression and Fixation of Degenerative Lumbosacral Spondylolisthesis Surgery in Pakistani Population. Cureus 11(8): e5493. DOI 10.7759/cureus.5493.

16. Khan MZ, Saeed M, Satar A, Iqbal A, Shah SHA.” Early out come of fusion surgery for spondylolisthesis” KJMS 2016, 9(1),41-44.

17. Vibert BT, Sliva CD, Herkowitz HN. Treatment of instability and spondylolisthesis: surgical versus nonsurgical treatment. Clin Orthop Relat Res. Feb 2006;443:222–227.

18. Herkowitz HN. Spine update: degenerative lumbar spondylolisthesis. Spine. 1995;20(9):1084–1090.

19. Zeng ZL, Jia L, Yu Y, et al.: Clinical outcomes of single-level lumbar spondylolisthesis by minimally invasive transforaminal lumbar interbody fusion with bilateral tubular channels. (Article in Chinese). Zhonghua Wai Ke Za Zhi. 2017, 55:279-284.

20. Kalichman L, Kim DH, Li L, Guermazi A, Berkin V, Hunter DJ. “Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community based population”. Spine. 2009, 34:199-205.