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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 17-22

Short-term functional evaluation of posterior lumbar interbody fusion done for degenerative spondylolisthesis at L4–L5 level


1 Department of Orthopaedics, Ghati Hospital and Government Medical College, Panchakki Road, Aurangabad, Maharashtra, India
2 Department of Neurosurgery, M G M Medical College and Hospital, Aurangabad, Maharashtra, India

Date of Submission31-Jan-2019
Date of Acceptance27-Apr-2020
Date of Web Publication26-Jun-2020

Correspondence Address:
Dr. Ansari Ishtyaque Abdul Aziz
Department of Neurosurgery, MGM Medical College, N-6, Cidco and Director, The Pacific Hospital, N-12, Plot 16, Aurangabad - 431 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_7_19

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  Abstract 


Context: Low back pain due to degenerative spondylolisthesis in the elderly especially the rural Indian population involved in farming and agriculture hard work is a common and incapacitating problem. Aims: Degenerative spondylolisthesis of L4/L5 is commonly observed with associated disc degeneration leading to foraminal stenosis causing radiculopathy and neuroclaudication. Materials and Methods: We have evaluated a short-term prospective follow-up of 26 patients treated with posterior lumbar interbody fusion (PLIF) with titanium pedicular screws and cage for L4–L5 degenerative lumbar spondylolysthesis (DLS) for 1, 3, and 6 months after surgery using Japanese Orthopaedic Association (JOA) criteria and MacNab's criteria. Statistical Analysis Used: Chi-square test or McNemar's Chi-square test. Results: The rate of improvement as calculated from the JOA score improved from 8.34 preoperatively to 72.19 at 6 months postoperative after PLIF for DLS and also good to excellent results in 84.61% of cases according to MacNab's criteria. Conclusions: Hence, we conclude that PLIF for DLS significantly improves quality of life postoperatively because of relief of back pain and neurological symptoms.

Keywords: Degenerative, neuroclaudication, posterior lumbar fusion, radiculopathy, spondylolisthesis


How to cite this article:
Aziz AM, Aziz AI. Short-term functional evaluation of posterior lumbar interbody fusion done for degenerative spondylolisthesis at L4–L5 level. J Orthop Traumatol Rehabil 2020;12:17-22

How to cite this URL:
Aziz AM, Aziz AI. Short-term functional evaluation of posterior lumbar interbody fusion done for degenerative spondylolisthesis at L4–L5 level. J Orthop Traumatol Rehabil [serial online] 2020 [cited 2020 Aug 7];12:17-22. Available from: http://www.jotr.in/text.asp?2020/12/1/17/287721




  Introduction Top


Degenerative lumbar spondylolisthesis (DLS) is a very common cause of severe back pain chronic in nature and affecting the elderly with subsequent neuroclaudication and leg, thigh, and buttock pains incapacitating and restricting the activities of daily living of elderly. Our study includes patients from rural farming population of marathwada region. These patients indulge in rural agriculture hard work involving repetitive lumbar flexion actions causing accelerated degeneration at L4–L5 level. It was first described by Junghanns as pseudospondylolisthesis in 1931 and subsequently by Macnab in 1950.[1],[2] The concept of degenerative spondylolisthesis (DLS) was refined and presented in modern way by Newman in 1955.[3] In their instructional course, lectures of the American Academy of Orthopaedic Surgeons, Bolesta and Bohlman have described the etiology, pathogenesis with emphasis, and surgeries for the treatment of DLS.[4],[5],[6]

Surgical management when indicated for the management for DLS has ranged from simple decompressive laminectomies to spinal arthrodesis, nowadays called spinal fusion surgeries to the use of instrumentation and of late, the use of devices used between vertebral bodies called as cages.[7],[8],[9],[10],[11],[12],[13],[14],[15] Spinal arthrodesis implies fusion of joints around the vertebral disc unit involving articular facets or vertebral interbody region.[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26]

Cloward is credited with describing the technique of posterior lumbar interbody fusion (PLIF).[27] The original described technique was later modified in many ways by other surgeons as described in literature by Steffee and Sitkowski and Roy-Camille et al.[28],[29] Various comparative studies have been done between PLIF and posterolateral fusion and the complications of PLIF commonly seen in the long term like adjacent segment degeneration have been documented.[30],[31],[32],[33],[34],[35] Recently, surgeons are doing endoscopic-assisted PLIF surgeries.[36] The purpose of this study was to evaluate the short-term functional outcome of PLIF in patients operated for L4-L5 degenerative spondylolisthesis with regard to the MacNab's score and Japanese Orthopaedic Association (JOA) criteria and monitor patient satisfaction after surgery till 6 months [Table 1].
Table 1: Japanese Orthopaedic Association's low back ache score

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  Materials and Methods Top


Study area and study population

Twenty-six patients were included in this prospective study, conducted in the department of neurosurgery and department of orthopedics at each of the authors working places, between August 2016 and December 2018. Patients were considered for the study if they fulfilled the following criteria.

Inclusion criteria

  1. Patient aged 50 years and above
  2. Single-level L4–L5 DLS
  3. Failure to respond to nonoperative treatment.


Exclusion criteria

  1. Patients below the age of 50 years
  2. Multiple-level disc herniation
  3. Vertebral fractures
  4. Disc prolapse with bowel and bladder symptoms (cauda equina syndrome)
  5. Patients with scoliosis or kyphosis
  6. Patients with spinal infection.


Sampling

Time period of the study – August 2016 to December 2018.

With the incidence rate of L4/5 DLS cases undergoing surgery 0.07% (70/100,000) at 95% confidence interval and + 1 margin of error, the sample size is n = 26.



Hence, a minimum number of 26 patients were included in this study.

Statistical analysis

  • Diagrammatic presentation
  • Mean ± standard deviation
  • Chi-square test or McNemar's Chi-square test
  • Paired t-test or suitable nonparametric test in case of skewed data (if necessary).


The study was approved by the local ethics committee.

Technique

A detailed history was obtained at the time of admission and all the patients were subjected to thorough clinical examination. All patients were subjected to magnetic resonance imaging (MRI).

The findings obtained therein were noted in a standard pro forma.

All the cases were assessed preoperatively and postoperatively with the JOA low backache score. The results of surgery are evaluated using MacNab's criteria.

After detailed clinical evaluation, the patients had undergone relevant investigations as follows:

  1. X-ray lumbosacral spine both anteroposterior (AP)/lateral views lateral flexion and extension views in standing position
  2. MRI whole spine
  3. Blood routine – Hb%, bleeding time (BT), clotting time (CT), fasting blood sugar, postprandial blood sugar, blood urea, serum creatinine
  4. Chest X-ray
  5. Electrocardiography/echocardiography for fitness for anesthesia
  6. Consent of the patient for the surgery.


Technique of surgery

All the patients were operated in prone position in knee–chest position on bolsters. The surgical procedure carried out was conventional standard central midline exposure with sideways exposure of L4 and L5 facets and lateral soft tissues right up to the tip of the transverse processes. Bilateral L4 and L5 titanium pedicular screws were inserted under C-arm guidance on AP and lateral visualization and confirmation. Interconnecting rod of any one side was applied. After midline exposure and screw insertion, L4-5 laminectomy was done. Bilateral L4 and L5 traversing and exiting nerve roots were identified and protected; epidural veins were cauterized with bipolar cautery. Intervertebral disc was identified and thorough complete discectomy was done with the help of curettes, interbody dilators, and reamers provided by the concerned company for ease of interbody disc space preparation and cage insertion. Once disc space is prepared for cage insertion, trial cage inserters were used to assess the size of the cage, which are provided by the company and intraoperative C-arm visualization helps assess perfect size of the interbody cage to be used. Then, the unilateral rod that was applied is distracted slowly under physiological limits carefully and judiciously. Anterior part of the disc space is filled with bone graft harvested and prepared from the laminectomy bone received by the OT assistant. Cage is placed or tapped into the position. Care is taken not to put it in lose fashion or overdistract the disc space. Final position of the cage is confirmed under C-arm. Both connecting rods are placed in position. Slight compression of rods is done to further hold the intervertebral cage tight in position and enhance stability and fusion. Average duration of surgery: 2 hours 30 minutes with a range of 2–4.5 hours depending on built (BMI-Body mass index) of the patient [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f, [Figure 1]g, [Figure 1]h, [Figure 1]h, [Figure 1]i, [Figure 1]j, [Figure 1]k.
Figure 1: Technique of posterior lumbar interbody fusion. (a) Intraoperative prone position of patient and C-arm. (b) Skin marking for midline incision. (c) Exposure in midline till tips of transverse process bilaterally. (d and e) Bilateral pedicle screw insertion. (f) Interbody trial of cage size after discectomy. (g) Bone graft for interbody cage. (h) Final picture after cage and rod application with decompressed spinal canal. (i and j) Preoperative X-rays and magnetic resonance imaging, (k)Postoperative X-ray at 6 months

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Average loss of blood: 200 ml with a range of 70–350 ml.

Blood transfusion was required in 7 patients. One patient with dural tear required suturing of dura with absorbable suture (no. 4.0 Vicryl) and a fat graft. Epidural bleeding was controlled by bipolar cautery and packing. One case of superficial wound infection required wound dressing and 3 days of antibiotics [Table 2].
Table 2: Immediate complications of surgery

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All patients were catheterized for 24 h postsurgery.

Fortunately, none of the above complications affected the final outcome.

Postoperative management

Postoperative intravenous antibiotics for 48 h and analgesia either intravenous or orally for 48–72 h depending on pain were administered. Neurological function was monitored. Turning in bed was allowed on the operative day. Patients were allowed to sit up on the 2nd postoperative day. Lower-limb strengthening exercises were started on the 2nd postoperative day. Back strengthening exercises were started on the 14th postoperative day. Patients were mobilized with brace on the 2nd postoperative day. Sutures were removed on the 12th postoperative day. Stooping and flexing the spine excessively were avoided by patients on advice. At discharge, patients were advised not to strain the back or lift weights. Patients were instructed to minimize sitting and riding in a vehicle 3 months postoperatively.

JOA rating scale was used to determine the outcome apart from MacNab's criteria. The total score represents the sum of subjective symptoms and objective findings.[37]




  Observations and Results Top


Observations

Total 26 patients were included in the study. All 26 patients were available for follow-up by visits. All the patients were followed up at the interval of 1 month, 3 months, and 6 months. At the end of 1 month and 6 months, assessment was done of subjective and objective findings with JOA score and the rate of improvement (RI) was calculated. Out of 26 patients, 18 were men and 8 were women [Table 1]. Age ranges from 28 years to 72 years. The mean age was 47.8 years. In males, age ranged from 28 to 72 years with a mean of 46.6 years. In females, age ranged between 35 and 70 years with a mean age of 50.5 years. All of the patients had both back pain and leg pain. In almost all the cases, back pain preceded leg pain (sciatica) except in one case who had complained leg pain to start with. Nine patients had right-sided radiculopathy and 13 patients had left-sided radiculopathy. Four patients had bilateral leg pain [Table 3], [Table 4], [Table 5], [Table 6].
Table 3: Distribution of patients according to occupation

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Table 4: Position of herniation

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Table 5: Neurological symptoms

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Table 6: Neurological deficits

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All 26 patients had undergone conservative therapy in the form of bed rest, traction, analgesics, or physiotherapy before undergoing our PLIF procedure.

Surgical outcome

For analyzing the clinical outcome of PLIF technique for DLS, we have used JOA score for preoperative and postoperative objective and subjective symptoms and RI at 1 month and 6 months [Table 7].
Table 7: Japanese Orthopaedic Association score and rate of improvement mean score

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MacNab's criteria of outcome [Table 8]:
Table 8: MacNab's criteria

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  1. Excellent – No pain; no restriction of mobility return to normal work and level of activity
  2. Good – Occasional nonradicular pain relief of presenting symptoms; return to modified work
  3. Fair – some improved functional capacity still handicapped and unemployed
  4. Poor – Continued objective symptoms of root involvement; additional operative intervention needed at the index level irrespective of length of postoperative follow-up.


Out of 26 patients at the time of discharge, 20 (87.5%) patients could walk independently without any aid and without any radicular pain. Six patients with little radicular pain and with support.

In most of the patients (19; 73.07%), sciatica improved immediately.

The clinical outcome of 26 patients after a mean follow up of 6 months is as follows:


  Discussion Top


In our study of 26 cases, our management involved PLIF with decompression. All patients during their follow-up showed an improvement in their clinical and functional outcome with regard to back pain and leg symptoms and effective return to their normal lifestyle.

The goal of PLIF in spondylolisthesis is to relieve back pain and the neurological deficit, to provide stability by fusion. Posterior approach and technique of fusion has distinct advantages over anterior approach because of its ease and accessibility and acquaintance of surgeon; it permits exploration of the defects, nerve roots, and intervertebral discs. In addition, it is relatively safe. A high rate of successful fusion by the PLIF technique has been reported by Watkins, Wiltse, and others. PLIF for DLS has definite biomechanical, anatomic, and physiologic advantages of interbody. Interbody support restores disc space height, facilitates correction of alignment and balance, prevents progression of subluxation, and provides load sharing to prolong the life of instrumentation. As the anterior and middle spinal columns support 80% of the spinal load, placing the bone graft loaded cage in this load-bearing position subjects it to compressive forces that enhance bony fusion.[38] Adding PLIF to pedicle screw fixation and posterior fusion after decompression in spondylolisthesis enhances fusion and stability leading to better functional outcomes and lower incidence of postoperative back pain.[39]

PLIF yields a satisfactory and long-lasting result and remains the gold standard against which other surgical treatment must be compared.[40]

The interbody fusion immediately produces a biomechanically stable postoperative spine, thus enhancing the opportunity for arthrodesis.


  Conclusion Top


In our study, there is a good correlation between interbody fusion and functional outcomes. Early return to work with better clinical and functional outcomes is observed with PLIF for DLS. A long-term study with a larger patient population with a detailed analysis of different types of interbody fusion devices could be done in future to establish the definitive role of CT in the assessment of interbody fusion and its associated long term outcomes or complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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