Hans Möller

Surgery versus conservative management in adult isthmic spondylolisthesis--a prospective randomized study: part 1.

STUDY DESIGN A prospective randomized study was performed. OBJECTIVE To determine whether posterolateral fusion in patients with adult isthmic spondylolisthesis results in an improved outcome compared with an exercise program. SUMMARY OF BACKGROUND DATA In spondylolisthesis, satisfactory results have been reported with both surgical and conservative management. The evidence for treatment efficacy, however, is weak because prospective randomized studies are lacking. METHODS In this study, 111 patients were randomly allocated to an exercise program (n = 34) or posterolateral fusion with or without transpedicular fixation (n = 77). The inclusion criteria were lumbar isthmic spondylolisthesis of any grade, at least 1 year of low back pain or sciatica, and a severely restricted functional ability in individuals 18 to 55 years of age. Pain and functional disability were quantified before treatment and at 1- and 2-year follow-up assessments by visual analog scales (VAS). RESULTS The 2-year follow-up rate was 93%. The functional outcome, as assessed by the Disability Rating Index and the pain reduction, was better in the surgically treated group than in the exercise group at both the 1- and 2-year follow-up assessments (P < 0.01). In the longitudinal analysis, the mean Disability Rating Index and pain improved in the surgical group (P < 0.0001). In the exercise group, the Disability Rating Index did not change at all, whereas the pain decreased slightly (P < 0.02). CONCLUSIONS Surgical management of adult isthmic spondylolisthesis improves function and relieves pain more efficiently than an exercise program.

Instrumented and Noninstrumented Posterolateral Fusion in Adult Spondylolisthesis : A Prospective Randomized Study : Part 2

STUDY DESIGN A prospective randomized study was performed. OBJECTIVE To determine whether transpedicular fixation improves the outcome of posterolateral fusion in patients with adult isthmic spondylolisthesis. SUMMARY OF BACKGROUND DATA The use of transpedicular fixation remains controversial. Both a positive effect and no effect from additional transpedicular fixation have been reported. METHODS In this study, 77 patients randomly underwent posterolateral fusion with (n = 37) or without (n = 40) transpedicular fixation. The inclusion criteria were lumbar isthmic spondylolisthesis of any grade, at least 1 year of low back pain or sciatica, and severely restricted functional ability in individuals 18 to 55 years of age. RESULTS The follow-up rate was 94%. At a 2-year follow-up assessment, the level of pain and functional disability were strikingly similar in the two groups, and there was no significant difference in fusion rate. CONCLUSIONS Lumbar posterolateral fusion performed in situ for adult isthmic spondylolisthesis relieves pain and improves function. The use of supplementary transpedicular instrumentation does not add to the fusion rate or improve the clinical outcome.

Symptoms, Signs, and Functional Disability in Adult Spondylolisthesis

STUDY DESIGN A cross-sectional clinical study. OBJECTIVES To determine whether there are specific symptoms, signs, and functional disability associated with adult spondylolisthesis. SUMMARY OF BACKGROUND DATA In spite of the common occurrence of adult spondylolisthesis, the symptoms, signs, and disability associated with it have not been analyzed in a large, well-defined group of patients. METHODS The symptoms, signs, and disability of 111 consecutive patients with adult spondylolisthesis, before randomized treatment with fusion or physiotherapy, were compared with those of 39 patients with nonspecific low back pain before lumbar fusion. The patients completed a questionnaire covering clinical history and symptoms and submitted a pain drawing. The signs were documented. Functional disability and pain were quantified by 12-function and 2-pain visual analog scales, respectively. RESULTS Sixty-two percent of the patients reported low back pain as well as sciatica, 7% sciatica only, and 31% low back pain only. Specific signs were infrequent. A positive straight leg raising test result in 12% and an L5 sensory disturbance in 13% were the most common. The symptoms were similar in patients with spondylolisthesis and chronic low back pain, but the chronic low back pain group reported more functional disability. Patients with a nonorganic pain drawing (widespread, nonspecific pain) were more often blue collar workers; were more often and longer on sick leave; and reported reduced mental condition, sexual function, functional ability, and more pain than patients with an organic pain drawing (localized, specific pain). CONCLUSIONS The clinical pattern and functional disability in adult spondylolisthesis and in low back pain of nonspecific origin are similar. Sciatica in adult spondylolisthesis is typically not associated with a positive straight leg raising test result.

Short segment bone-on-bone instrumentation for single curve idiopathic scoliosis.

Study Design. Retrospective case series review. Objectives. To evaluate the outcomes of a new short segment anterior scoliosis technique with complete removal of the discs, bone-on-bone apposition of the vertebral bodies, and dual rod instrumentation. To evaluate a new preop planning technique for scoliosis instrumentation. Summary of Background Data. Scoliosis surgery traditionally was performed via a posterior approach, but anterior scoliosis instrumentation has proven to be superior regarding the amount of curve correction and the number of segments saved from instrumentation. Methods. Thirty-one patients with single curve idiopathic scoliosis less than 75° were operated using the bone-on-bone surgical technique with dual rod instrumentation (Kaneda Anterior Scoliosis System, Depuy AcroMed, Raynham, MA from 1996 until 2001). Average follow-up was 40 months (range 15–77 months). Results. Surgical correction of the major curve averaged 73.9% over the instrumented levels and 51.4% over the entire curve. The average number of discs fused was 4.6 for thoracic curves and 3.3 for thoracolumbar and lumbar curves. There were no implant-related complications or nonunions. The compensatory curves spontaneously improved by an average of 38.6%. Uneventful healing of all fusions occurred—most within 8 to 12 weeks. One compensatory thoracic curve progressed and posterior instrumentation was done 28 months after correction of the major thoracolumbar curve. Conclusions. Surgical correction was achieved in over half the levels that would have been operated by standard posterior segmental fixation. Bony healing due to the bone-on-bone apposition was achieved uneventfully after apical correction of the spinal curvature in all patients. Use of dual rod instrumentation (Kaneda Anterior Scoliosis System) is fundamental in maintaining the correction of the curvature achieved in the operating room. The preoperative planning technique worked well.

Predictive factors for the outcome of fusion in adult isthmic spondylolisthesis.

Study Design. A prospective study on predictive factors for the outcome of 164 patients with adult isthmic spondylolisthesis operated on with fusion. Objective. In view of the need to better select patients for fusion, we investigated the use of the pain drawing (PD) and other potential factors for predicting the outcome of fusion. Summary of Background Data. Results on predictive factors of outcome after spinal fusion have been contradictory and large, well-defined, patient samples with adequate observation times are lacking. Methods. Questionnaires including possible predictive factors and PDs were obtained before surgery. Degree and level of slip were documented. Outcome was quantified by measurement of pain (VAS), Disability Rating Index, the Oswestry Disability Index, and global assessment by the patient into “much better,” “better,” “unchanged,” or “worse.” The 2-year follow-up rate was 160 of 164 (98%). Results. In the total sample 49% of patients were much better, 25% better, 14% unchanged, and 12% worse. The following preoperative factors correlated to a worse outcome in the univariate analysis: not working, no regular exercise, female gender, shortness in stature, and a nonorganic PD. The multivariate regression analysis showed that work status was the main determinant of outcome. Gender and exercise had less but significant impact (P = 0.004 and 0.02, respectively). In the multivariate regression analysis the PD was not a significant predictor (P = 0.06). Conclusion. The present study shows that patients working before surgery have a more favorable outcome. Also male gender and regular exercise are indicators of a better outcome after fusion. Female patients not working, not exercising or, if these factors are not known, with nonorganic PDs, should be informed about their suboptimal chances of an excellent outcome after fusion.

Prevalence of Back Problems in 1069 Adults With Idiopathic Scoliosis and 158 Adults Without Scoliosis.

Study Design. Multicenter case-control study. Objective. To investigate the prevalence of back problems in adults with idiopathic scoliosis. Summary of Background Data. Information on the prevalence of back problems in adults with idiopathic scoliosis is scarce, especially in untreated individuals, males, and individuals with an age at the onset of scoliosis of less than 10 years. Methods. A total of 1069 individuals with idiopathic scoliosis and 158 individuals without scoliosis, all aged 20 to 65 years, answered a questionnaire on back problems. Individuals with scoliosis were diagnosed between ages 4 and 20 years and any treatment was terminated before the age of 20 years. Logistic regression or analysis of variance was used for group comparisons. Results. Mean (SD) age at the time of investigation in individuals with scoliosis (123 males and 946 females) was 41 (9) years, and in individuals without scoliosis (75 males and 83 females) 45 (13) years. Three hundred seventy-four individuals with scoliosis were untreated, 451 had been brace treated, and 244 were surgically treated. The mean prevalence of back problems was 64% in the individuals with scoliosis and 29% in the individuals without scoliosis (P < 0.001). Among the untreated individuals with scoliosis, 69% reported back problems; among the brace treated, 61%; and among the surgically treated, 64% (P = 0.06). When comparing females and males with scoliosis, and individuals with juvenile and adolescent scoliosis, there were no statistically significant differences in the prevalence of back problems (P = 0.10 and P = 0.23, respectively). Conclusion. Adults with idiopathic scoliosis have a higher prevalence of back problems than individuals without scoliosis. Treatment, sex, and juvenile or adolescent onset of diagnosis was not related to the prevalence of back problems in adulthood. Level of Evidence: 2

An observational study on the outcome after surgery for lumbar disc herniation in adolescents compared with adults based on the Swedish Spine Register

BACKGROUND CONTEXT Disc-related sciatica has a prevalence of about 2% in adults, but is rare in adolescents. If conservative treatment is unsuccessful, surgery is an option. PURPOSE The aim of this study was to compare the outcomes of surgery for lumbar disc herniation in adolescents with adults in the Swedish Spine Register. STUDY DESIGN/SETTING This is a prospective observational study: National Quality Register. PATIENT SAMPLE This study included 151 patients, 18 years or younger, 4,386 patients, 19-39 years, and 6,078 patients, 40 years or older, followed for 1-2 years after surgery. OUTCOME MEASURES The primary outcomes were patient satisfaction and global assessment of leg and back pain. Secondary outcomes were Visual Analog Scale (VAS) leg pain, VAS back pain, Oswestry disability index (ODI), and EuroQol-5 dimensions (EQ-5D). METHODS Statistical analyses were performed with the Welch F test, the chi-square test, and the Wilcoxon signed-rank test. RESULTS At follow-up, 86% of the adolescents were satisfied compared with 78% in the younger adults and 76% in the older adults group (p<.001). According to the global assessment, significantly decreased leg pain was experienced by 87% of the adolescents, 78% of the younger adults, and 71% of the older adults (p<.001). Corresponding figures for back pain were 88%, 73%, and 70%, respectively (p<.001). All groups experienced significant postoperative improvement of VAS leg pain, VAS back pain, ODI, and EQ-5D (all p<.001). CONCLUSIONS The adolescent age group was more satisfied with the treatment than the adult groups. There was a significant improvement in all age groups after surgery.

Long-term outcome after spinal fusion for isthmic spondylolisthesis in adults

BACKGROUND CONTEXT Data on the long-term outcome after fusion for isthmic spondylolisthesis are scarce. PURPOSE To study patient-reported outcomes and adjacent segment degeneration (ASD) after fusion for isthmic spondylolisthesis and to compare patient-reported outcomes with a control group. STUDY DESIGN/SETTING A prospective study including a cross-sectional control group. PATIENT SAMPLE Patients with isthmic spondylolisthesis underwent posterior lumbar interbody fusion (PLIF) (n=86) or posterolateral fusion (PLF) (n=77). Patient-reported outcome data were available for 73 patients in the PLIF group and 71 in the PLF group at a mean of 11 (range 5-16) years after baseline. Seventy-seven patients in the PLIF group and 54 in the PLF group had radiographs at a mean of 14 (range 9-19) years after baseline. One hundred thirty-six randomly selected persons from the population served as controls for the patient-reported outcomes. OUTCOME MEASURES Patient-reported outcomes include the following: global outcome, Oswestry Disability Index, Disability Rating Index, and Short Form 36. The ASD was determined from radiographs using the University of California Los Angeles (UCLA) grading scale. METHODS The chi-square test or analysis of covariance (ANCOVA) was used for group comparisons. The ANCOVA was adjusted for follow-up time, smoking, Meyerding slippage grade, teetotaler (yes/no) and, if available, the baseline level of the dependent variable. RESULTS There were no significant patient-reported outcome differences between the PLIF group and the PLF group. The prevalence of ASD was 42% (32/77) in the PLIF group and 26% (14/54) in the PLF group (p=.98). The patient-reported outcome data indicated lower physical function and more pain in individuals with surgically treated isthmic spondylolisthesis compared to the controls. CONCLUSIONS PLIF and PLF groups had similar long-term patient-reported and radiological outcomes. Individuals with isthmic spondylolisthesis have lower physical function and more pain several years after surgery when compared to the general population.

Short-segment bone-on-bone fusion of adolescent idiopathic scoliosis using Kaneda Anterior Spinal System

Abstract Purpose of study: The objective of this study was to evaluate a new technique for treatment of idiopathic scoliosis with a single major curve using the short-segment, bone-on-bone approach and the Kaneda Anterior Spinal System (KASS). This report describes the technique and presents the results for our first 10 patients. Methods used: The short-segment bone-on-bone KASS technique was performed in 10 consecutive patients with adolescent idiopathic thoracic or thoracolumbar scoliosis. The mean age was 14.4 years (12 to 20 years), and the average follow-up was 44 months (range, 34 to 61 months). None were lost to follow-up. of findings: Preoperatively, the major curve averaged 48 degrees (38 to 55 degrees); this corrected to 11 degrees (0 to 20 degrees) postoperatively (77% correction rate). Preoperative compensatory curves measured 34 degrees (29 to 39 degrees); these spontaneously corrected to 13 degrees postoperatively (62% correction rate) as a consequence of correction of primary curve. The preoperative tilt angle was 20 degrees (14 to 28 degrees). Postoperatively the tilt angle was reduced to 6 degrees (2 to 10 degrees). The tilt angle correction was 70%. The fusion was healed and postoperative immobilization discontinued 6 to 10 weeks after the procedure. There was no loss of correction. The average number of vertebra fused using our technique was five (four discs). The average number of posterior fusion levels are proposed by King was 10. There were no implant problems, nonunions or serious peri- or postoperative complications. Relationship between findings and existing knowledge: The bone-on-bone short-segment technique permits correction of single-curve idiopathic scoliosis below 75 degrees over half the levels that have been traditionally operated on by posterior instrumentation, yet provides 77% average correction with no nonunion, no loss of correction and healing in 6 to 8 weeks. Overall significance of findings: The new short-segment, bone-on-bone approach for single major curves using the KASS instrumentation provides excellent correction over half the levels operated on by previous posterior systems with rapid fusion and with no loss of correction. Disclosures: Device or drug: Kaneda Anterior Spinal System. Status: approved. Conflict of interest: Robert Gaines, consultant speakers bureau; and, other support from De Puy Acromed.