Akbarnia_Spondylo

8/7/2019 Akbarnia_Spondylo

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Isthmic Spondylolisthesis:

Anterior vs Posterior Fusion Clinical Professor, University of California, San Diego

Medical Director, San Diego Centerfor Spinal Disorders La Jolla, California

Behrooz A. Akbarnia, MD


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Disclosures

(a) DePuy Spine, Nuvasive, K2M(b) DePuy Spine, Nuvasive, K2M(c) Nuvasive, K2M

a. Grants/Research Supportb. Consultant

c. Stock/Shareholderd. Speakers Bureaue. Other Financial Support


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Isthmic Spondylolisthesis:

CausesRepetitive

hyperextensionGymnasts, footballlinemen, rugbyScheuermanndisease


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Spondylolisthesis

V = Spondyloptosis

Myerding Classification

HIGH

GRADE

LOW

GRADE


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Marchetti and Bartolozzi1982

DevelopmentalDue to lysis

Due to elongationTraumatic

Acute fxStress fx

Acquired

IatrogenicPathologicDegenerative


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RB


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Key Management Issues

Character of Symptoms Pain Neurological dysfunction

DeformityDevelopemental or Aquired ? amount of dysplasia

Adult or Pediatric ?


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Spondylolysis & Spondylolisthesis:

Treatment

Up to 50% slip, asymptomatic : observe, consider

high risk athletic restriction if >25%Up to 50% slip, symptomatic : activitymodification, PT, bracing

Greater than 50% slip : consider surgery

Pediatric


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Spondylolysis & Spondylolisthesis:Surgical Options

In-situ Posterolateral Fusion

Gold Standard for low gradeDirect Repair of the ParsFibular strut grafting (Bohlman)

Transsacral FixationReduction and fusion

Pediatric


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In Situ fusion

Does in situ fusion leaves anydisability behind?


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DR


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DR


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14 years Boy


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CT 1/2009


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Post OP


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Comparison


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AS 16/F spondylolisthesis


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16 years oldPre-op

Sacroplasty, wide decompression of nerve roots, monitoring


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Follow up 48 mos


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Isthmic Spondylolisthesis:Nonoperative Treatment

NSAIDsPain Management

Physical TherapyWeight lossESI, facet injections

Bracing (comfort, not for healing)

Most patients improve within 3 months

Adults


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Indications for Surgery

Severe back/leg pain

Progressive neurologic deficitProgressionCauda equinaCosmesis

Adults


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Surgical Options

Direct repair of the parsDecompression alone (Gill Laminectomy)Decompression with in situ fusion

+/- instrumentation

Interbody fusion and fixationReduction and fixationVertebrectomy

Adults


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Decompression alone

Decompression alone is not indicated inpediatric and adolescent patients

Gill et al reported good early results withdecompression alone

Gill et al. JBJS Am 1955 Several authors later reported high rate of slip

progression and unsatisfactory results Osterman et al. CORR 1976 Marmor et al. JBJS Am 1961

Considered a possibility in elderly withcomordities


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Posterolateral fusion

Gold standardPediatric and adolescent Fusion rates >90% 75-100% good to excellent results

Adults Fusion rates variable 33-100% Is it the Gold standard in adults??????


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Fusion disease stripping paraspinal musculature Does not address anterior column

Can continue to have discogenic pain Barrick et al.

Pts had back pain despite solid PLF Improved with ALIF

LHeareaux et al. and La Rosa et al. Correction of slip angle lost over time because of disc

space collapse despite solid PLF


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Instrumentation not proven to improveresults

McGuire and Admundson Spine 1993 78% fusion with instrumentation 72% fusion without instrumentation

Moller and Hedlund Spine 2000 65% fusion with 78% fusion without No difference in clinical outcome


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Plain Radiographs


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MRI


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L4

S1


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Anterior Lumbar Interbody

FusionDiscectomy helps to correct slip angleBone graft in compressive environment optimal for fusionAvoids stripping of paraspinal muscles Vessel, bowel, retrograde ejaculation

Indirect decompression Direct decompression not possible


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Anterior Lumbar Interbody

FusionIshihara et al J Spinal Disord 2001 Minimum 10 year follow up

83% fusion rateVan Rens and van Horn Acta Orthop Scand1982 90% fusion rate


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Anterior and Posterior Fusion

ALIF and PSF (360) TLIF

PLIF Promote higher fusion rates Combines all benefits of ALIF with benefits

from PLF Longer operaterative times More complications


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A.H.

44 yo Female Back pain since high-school

Managed with activity self-regulationNow, increasing pain frequency/durationdecreasing pain free periods

Last 1 yr also c/o RLE pain/numbness


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ALIF vs PLIF/TLIF Kim et al. J Spinal Disord Tech 2009 Mini-

transforaminal lumbar interbody fusion versusanterior lumbar interbody fusion augmented bypercutaneous pedicle screw fixation: acomparison of surgical outcomes in adult low-

grade isthmic spondylolisthesis (2 year followup) ALIF vs TLIF - Fusion 95% vs 92%, clinical outcomes

similar

ALIF significant difference pre to post disc height,segmental lordosis, whole lumbar lordosis Could potentially see clinical differences long term with

improved lordosis at instrumented levels (i.e. ASD, sagbalance)


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CoclusionsOutcomes are significantly different betweenpediatric and adult groupsGood long term outcomes can be expected with

posterior approach in most pediatric and manyadultsAnterior approach allows better fusion rate andmay be better correctionAnterior and posterior approach may allow thebest alignment and fusion but carries higher risks


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