Radiological adjacent-segment degeneration in L4–5 spondylolisthesis: comparison between dynamic stabilization and minimally invasive transforaminal lumbar interbody fusion

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OBJECTIVE

Pedicle screw–based dynamic stabilization has been an alternative to conventional lumbar fusion for the surgical management of low-grade spondylolisthesis. However, the true effect of dynamic stabilization on adjacent-segment degeneration (ASD) remains undetermined. Authors of this study aimed to investigate the incidence of ASD and to compare the clinical outcomes of dynamic stabilization and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF).

METHODS

The records of consecutive patients with Meyerding grade I degenerative spondylolisthesis who had undergone surgical management at L4–5 in the period from 2007 to 2014 were retrospectively reviewed. Patients were divided into two groups according to the surgery performed: Dynesys dynamic stabilization (DDS) group and MI-TLIF group. Pre- and postoperative radiological evaluations, including radiography, CT, and MRI studies, were compared. Adjacent discs were evaluated using 4 radiological parameters: instability (antero- or retrolisthesis), disc degeneration (Pfirrmann classification), endplate degeneration (Modic classification), and range of motion (ROM). Clinical outcomes, measured with the visual analog scale (VAS) for back and leg pain, the Oswestry Disability Index (ODI), and the Japanese Orthopaedic Association (JOA) scores, were also compared.

RESULTS

A total of 79 patients with L4–5 degenerative spondylolisthesis were included in the analysis. During a mean follow-up of 35.2 months (range 24–89 months), there were 56 patients in the DDS group and 23 in the MI-TLIF group. Prior to surgery, both groups were very similar in demographic, radiological, and clinical data. Postoperation, both groups had similarly significant improvement in clinical outcomes (VAS, ODI, and JOA scores) at each time point of evaluation. There was a lower chance of disc degeneration (Pfirrmann classification) of the adjacent discs in the DDS group than in the MI-TLIF group (17% vs 37%, p = 0.01). However, the DDS and MI-TLIF groups had similar rates of instability (15.2% vs 17.4%, respectively, p = 0.92) and endplate degeneration (1.8% vs 6.5%, p = 0.30) at the cranial (L3–4) and caudal (L5–S1) adjacent levels after surgery. The mean ROM in the cranial and caudal levels was also similar in the two groups. None of the patients required secondary surgery for any ASD (defined by radiological criteria).

CONCLUSIONS

The clinical improvements after DDS were similar to those following MI-TLIF for L4–5 Meyerding grade I degenerative spondylolisthesis at 3 years postoperation. According to radiological evaluations, there was a lower chance of disc degeneration in the adjacent levels of the patients who had undergone DDS. However, other radiological signs of ASD, including instability, endplate degeneration, and ROM, were similar between the two groups. Although none of the patients in the present series required secondary surgery, a longer follow-up and a larger number of patients would be necessary to corroborate the protective effect of DDS against ASD.

ABBREVIATIONS ASD = adjacent-segment degeneration; DDD = degenerative disc disease; DDS = Dynesys dynamic stabilization; JOA = Japanese Orthopaedic Association; MI-TLIF = minimally invasive transforaminal lumbar interbody fusion; ODI = Oswestry Disability Index; ROM = range of motion; VAS = visual analog scale.

Article Information

Correspondence Jau-Ching Wu: Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan. jauching@gmail.com.

INCLUDE WHEN CITING Published online June 1, 2018; DOI: 10.3171/2018.1.SPINE17993.

CH Kuo and WC Huang contributed equally to this paper.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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Figures

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    Clinical outcomes measured according to the average VAS back pain score, with significant improvement postoperatively but without significant difference between the MI-TLIF and DDS groups at different time points.

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    Clinical outcomes measured according to the average VAS leg pain score, demonstrating significant improvement postoperatively. There were no significant differences between the MI-TLIF and DDS groups at each time point.

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    Clinical outcomes measured according to the ODI, demonstrating significant improvement postoperatively. There were no significant differences between the MI-TLIF and DDS groups at each time point.

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    Clinical outcomes measured according to the JOA scores, demonstrating significant improvement postoperatively. There were no significant differences between the MI-TLIF and DDS groups at each time point.

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    A 48-year-old female had low-back pain and bilateral leg pain for years. Preoperative MRI demonstrated spinal stenosis at L4–5 caused by a bulging annulus fibrosis and hypertrophic ligamentum flavum (A and C) with Meyerding grade I spondylolisthesis (E). After L-4 laminectomy and DDS, she experienced symptom relief, and the 2-year follow-up images demonstrated a stable construct of the DDS without listhesis (F) and little spinal stenosis or disc degeneration (B and D).

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    A 58-year-old female presented with low-back pain, bilateral leg pain, and claudication. Preoperative MRI demonstrated spinal stenosis at L4–5 caused by a bulging disc and hypertrophic ligamentum flavum (A and C), and lateral radiography showed Meyerding grade I spondylolisthesis (E). She underwent MI-TLIF (B). Two-year follow-up MRI demonstrated disc degeneration over the cranial and caudal adjacent levels (D, asterisks), and lateral radiography also revealed L5–S1 listhesis (F, arrowhead). To date, the patient has remained free of symptoms and has been closely followed up.

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