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Spondylolysis and Spondylolisthesis - Dynamic …

14/12/2017 · High-grade dysplastic spondylolisthesis is extremely rare and always involves the L5-S1 level

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Spondylolysis and Spondylolisthesis

For individuals who have spinal stenosis undergoing decompression surgery who receive lumbar spinal fusion, the evidence includes randomized controlled trials (RCTs) with mixed results. Relevant outcomes are symptoms, functional outcomes, quality of life, resource utilization, and treatment-related morbidity. Two RCTs published in 2016 compared decompression surgery plus fusion to decompression surgery alone. These trials reached different conclusions about the benefit of adding fusion to decompression, one specifically in patients with low-grade (0%-25% slippage) spondylolisthesis and one in patients with lumbar stenosis with or without spondylolisthesis. Both trials reported a larger number of operative and perioperative adverse outcomes with the addition of fusion. The Swedish Spinal Stenosis Study found no benefit of surgery related to clinical outcomes, while the Spinal Laminectomy versus Instrumented Pedicle Screw trial reported a small benefit in clinical outcomes and a reduction in the number of subsequent surgeries when fusion was added to decompression. In the earlier Spine Patient Outcomes Research Trial (SPORT), decompression surgery plus fusion was compared to conservative, nonsurgical treatment. Ninety-five percent of patients in the surgical group underwent decompression with fusion and had better outcomes than patients receiving nonoperative therapy. This trial, however, did not isolate the impact of fusion from that of decompression surgery. The evidence is insufficient to determine the effects of the technology on health outcomes.

Biomechanics of the L5/S1 Junction and the Effect of Spondylolisthesis and ..
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One of the studies that compared surgical and nonsurgical treatment for CLBP was a 2001 multicenter trial by the Swedish Lumbar Spine Study Group.20 In this trial, 294 patients with CLBP for at least 2 years, sick leave or disability for at least 1 year (mean, 3 years), and radiologic evidence of disc degeneration were randomized into 1 of 3 types of spinal fusion or to physical therapy supplemented by other nonsurgical treatment. Patients were excluded if they had specific radiologic findings such as spondylolisthesis, new or old fractures, infection, inflammatory process, or neoplasm. With intention-to-treat analysis, the surgical group showed greater reductions than the nonsurgical group in back pain (33% vs 7%), disability according to ODI score (25% reduction vs 6% reduction), visual analog scale (VAS) score (28% vs 8%), and General Function Score (31% vs 4%). Significantly more surgical patients were also back to work (36% vs 13%) and more reported their outcomes as better or much better (63% vs 29%).

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Lumbar fusion should be performed for patients whose low back pain refractory to conservative treatment (physical therapy or other nonoperative measures) and is due to 1- or 2-level DDD without stenosis or spondylolisthesis

Surgical decompression and fusion is recommended as an effective treatment alternative for symptomatic stenosis associated with degenerative spondylolisthesis in patients who desire surgical treatment.

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In 2007 and 2009, Weinstein et al reported findings from the widely cited multicenter controlled trial (Spine Patient Outcomes Research Trial [SPORT]). The primary comparison in this trial was decompression surgery plus fusion compared to nonsurgical treatment for patients with lumbar spinal stenosis and degenerative spondylolisthesis.6,7 All patients had neurogenic claudication or radicular leg pain associated with neurologic signs, spinal stenosis shown on cross-sectional imaging, and degenerative spondylolisthesis shown on lateral radiographs with symptoms persisting for at least 12 weeks. There were 304 patients in a randomized cohort and 303 patients in an observational cohort. About 40% of the randomized cohort crossed over in each direction by 2 years of follow-up. At the 4-year follow-up, 54% of patients randomized to nonoperative care had undergone surgery. Five percent of the surgically treated patients received decompression only and 95% underwent decompression with fusion. Analysis by treatment received was used due to the high percentage of crossovers. This analysis, controlled for baseline factors, showed a significant advantage for surgery at up to 4 years of follow-up for all primary and secondary outcome measures.

Section Summary: Isthmic Spondylolisthesis
One RCT was identified; it compared fusion to an exercise program for adults with symptomatic isthmic spondylolisthesis. Functional outcomes and pain relief were significantly better following fusion surgery. Results of this trial support the use of fusion for this condition, but should be corroborated in a larger number of patients.

Original Article from The New England Journal of Medicine — Laminectomy plus Fusion versus Laminectomy Alone for Lumbar Spondylolisthesis Original Article from The New England Journal of Medicine — Laminectomy plus Fusion versus Laminectomy Alone for Lumbar Spondylolisthesis
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  • Sections Lumbar Spondylolysis and Spondylolisthesis.

    Spondylolisthesis

  • Spondylolisthesis: Get a 2nd, 3rd, and 4th Opinion! Please!

    Spondylolisthesis Grades

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    Spondylolisthesis can be described according to its degree of severity

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While Spondylolisthesis itself is not a rare condition and ..

Lumbar spinal fusion is more controversial when the conditions previously described are not present. Spinal stenosis is 1 such condition. A 2011 consensus statement from the North American Spine Society (NASS) has defined degenerative lumbar spinal stenosis as a condition in which there is diminished space available for the neural and vascular elements in the lumbar spine secondary to degenerative changes in the spinal canal.1 When symptomatic, this causes a variable clinical syndrome of gluteal and/or lower-extremity pain and/or muscle fatigue, which may occur with or without back pain. Decompression surgery is indicated for patients with persistent symptoms despite conservative treatment, and spinal fusion is frequently performed in combination with decompression surgery for this purpose, with the intent decreasing instability of the spine. One potential marker of instability is spondylolisthesis, and many surgeons target patients with spinal stenosis and spondylolisthesis for the combined decompression plus fusion procedure. NASS has defined lumbar degenerative spondylolisthesis as an acquired anterior displacement of 1 vertebra over the subjacent vertebra, associated with degenerative changes, but without an associated disruption or defect in the vertebral ring.2 Most patients with symptomatic degenerative lumbar spondylolisthesis and an absence of neurologic deficits do well with conservative care. Patients who present with sensory changes, muscle weakness, or cauda equina syndrome are more likely to develop progressive functional decline without surgery.

Degenerative spondylolisthesis symptoms include ..

In the Swedish Spinal Stenosis Study (SSSS), 247 patients between 50 and 80 years of age who had lumbar spinal stenosis at 1 or 2 levels were randomized to decompression plus fusion surgery or decompression surgery alone.3 The specific surgical method for decompression and fusion was determined by the surgeon. Randomization was stratified by the presence of degenerative spondylolisthesis, which was present in about half of the patients. Analysis was prespecified to be per-protocol. The addition of fusion to laminectomy resulted in longer operating time, more bleeding, higher surgical costs, and longer hospitalization. The primary outcome measure, the Oswestry Disability Index (ODI) score (range, 0-100; with higher scores indicating severe disability), did not differ significantly between groups at the 2- or 5-year follow-ups. At 2 years, the difference in change in ODI score did not differ significantly between fusion and decompression-only groups (-2; 95% CI -7 to 3; p=0.36). Mean scores were also analyzed separately for patients with or without spondylolisthesis. In patients with degenerative spondylolisthesis (range, 7.4-14.3 mm), the mean ODI score at 2 years was 25 in the fusion group and 21 in the decompression-alone group. The distance walked in 6 minutes (6-minute walk test) did not differ significantly between groups. Additional lumbar spine surgery during 6.5 years of follow-up was performed in a similar percentage of patients in the fusion group (22%) and the decompression-alone group (21%). Of the 153 patients who had enrolled early enough to have 5 years of follow-up, there were no significant differences in ODI results.

Spondylolisthesis In Adults - Orthospine

For individuals who have isthmic spondylolisthesis who receive lumbar spinal fusion, the evidence includes 1 RCT. Relevant outcomes are symptoms, functional outcomes, quality of life, resource utilization, and treatment-related morbidity. One RCT identified compared fusion to an exercise program for patients with symptomatic isthmic spondylolisthesis. Functional outcomes and pain relief were significantly better after fusion surgery. Results of this trial support the use of fusion for this condition, but should be corroborated in a larger number of patients. The evidence is insufficient to determine the effects of the technology on health outcomes.

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