5:06162. Preserving the degenerated L5S1 segment in degenerative lumbar fusion surgery in older...
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Proceedings of the NASS 20th Annual Meeting / The Spine Journal 5 (2005) 1S–189S 84S 5:36 161. PLIF vs. posterolateral fusion in adult isthmic spondylolisthesis Per Ekman, MD 1 , Rune Hedlund, MD 2 , Hans Mo ¨ller, MD, PhD 2 , Tycho Tullberg 3 , Pavel Neuman 4 ; 1 Karolinska Institute, Stockholm, Sweden; 2 Karolinska University Hospital / Huddinge, Karolinska Institute, Stockholm, Huddinge, Sweden; 3 Stockholm Spine Center, Stockholm, Sweden; 4 Ryhovs Hospital, Jo ¨nko ¨ping, Sweden BACKGROUND CONTEXT: Based on a RCT we have previously re- ported an improved outcome 2 years after posterolateral fusion (PLF) compared with exercise in adult isthmic spondylolisthesis. On theorethical grounds PLIF has been suggested to result in an improved outcome com- pared with PLF. Data to support this view is, however, lacking. PURPOSE: To compare the outcome of PLIF with PLF in adult isthmic spondylolisthesis. STUDY DESIGN/SETTING: The outcome of prospectively identified adult patients with isthmic spondylolisthesis operated on with PLIF were compared with historical controls operated on with posterolateral fusion (PLF). PATIENT SAMPLE: In this multi-center study 86 patients, age 18–55, with symptomatic adult isthmic spondylolisthesis were operated on with PLIF. The control group consisted of a historical group of 77 patients operated on with PLF. The two groups had similar socioeconomic, age and sex distribution, and similar level of pain and disability. OUTCOME MEASURES: Preoperatively and at 2 years follow-up func- tional disability was quantified by the Disability Rating Index (DRI, 0– 100) and pain by VAS. The Oswestry score was quantified at 2 year follow- up. Global outcome was assessed by the patient as much better, better, unchanged or worse. METHODS: The inclusion criteria and methods of outcome measurements were identical in the PLIF and PLF-groups. The PLIF-group were operated on with autograft and carbon fibre ramps with pedicle fixation. The PLF- group consisted of 40 patients operated with posterolateral fusion and 37 patients operated on with autograft and pedicle fixation. RESULTS: The follow-up rate at present (Jan-05) is 83% (71/86 patients). Based on these patients the pain index improved from 66 preoperatively to 36 (p0.0001), and the DRI from 46 to 31 (p0.01). Level of pain and DRI were similar to that of the historical PLF group (pain 37, DRI 29, ns). Similarly, the global outcome was almost identical in the two groups; 71% of the patients in the PLIF-group classified the results as much better or better compared with 75% in the PLF group (ns). The Oswestry score where the same (26) in both groups at 2 year follow-up. CONCLUSIONS: Type of fusion, PLIF or PLF, is of limited importance for the outcome of surgical treatment of adult isthmic spondylolisthesis. Despite the theorethical advantages of PLIF no improvement on patient outcome compared with posterolateral fusion could be demonstrated, ques- tioning the need of anterior support in short lumbar fusions. DISCLOSURES: FDA device/drug: Ramps for PLIF. Status: Approved for this indication. CONFLICT OF INTEREST: No conflicts. doi: 10.1016/j.spinee.2005.05.164 Friday, September 30, 2005 5:06–5:55 PM Concurrent Session: Degenerative 5:06 162. Preserving the degenerated L5S1 segment in degenerative lumbar fusion surgery in older patients: is it possible? Stanley Lee, MD 1 , Lawrence Lenke, MD 2 , Michael Peelle, MD 2 , Gbolahan Okubadejo, MD 3 , Ivan Cheng, MD 4 , Robert Hurford, Jr., MD 5 , Keith Bridwell, MD 6 , Brenda Sides, BA 6 , Georgia Stobbs, RN 6 ; 1 University of Michigan, Ann Arbor, MI, USA; 2 Washington University in St. Louis, St. Louis, MO, USA; 3 Washington University Medical School, St. Louis, MO, USA; 4 Stanford School of Medicine, Stanford, CA, USA; 5 Carle Spine Institute, Urbana, IL, USA; 6 Washington University Medical Center, St. Louis, MO, USA BACKGROUND CONTEXT: Spine surgeons are often faced with a dilemma of whether to include a degenerated L5-S1 fusion in a lumbar fusion for degenerative disease. Most patients with degenerative lumbar conditions present with some degeneration at L5-S1 that is of questionable clinical significance. Fusion to S1 versus L5 presents additional perioperative risk and increased incidence of late pseudarthrosis. PURPOSE: To evaluate radiographic and clinical outcomes in degenerative lumbar spine patients fused to L5 versus S1. We hypothesize that in older, less active patients, fusion to L5 versus S1 provides similar outcomes with less morbidity. STUDY DESIGN/SETTING: A retrospective review of 69 consecutive patients a one institution by two surgeons who underwent lumbar fusion of 7 or less levels for degenerative disease comparing outcomes of those patients fused to L5 versus S1. Strong consideration was given to stopping surgical fusion at L5 versus S1 in patients above age 65. PATIENT SAMPLE: 44 were fused to L5 and 25 were fused to S1. There were 19 men and 50 women with and average age of 65 at surgery (range 43–77). Within the L5 group, the mean age was 67 (64%65) and within the S1 group, the mean age was 56 (84%65). The majority of the patient underwent surgery for degenerative disease of the lumbar spine with a component of stenosis. Other diagnoses included adult scoliosis, post lami- nectomy syndrome, and spondylolisthesis. OUTCOME MEASURES: Preoperative, postoperative, and final follow- up radiographs were reviewed for coronal curve, L5 depth, Weiner degener- ative disc rating, T12-S1 and L5-S1 lordosis, anterior and posterior L5-S1 disc height, L5-S1 olisthesis, and T12 sagittal plumb. Functional outcome was measured by a 14 question institutional postoperative status question- naire that evaluated activity level, function, pain, cosmesis, and patient’s overall outlook. METHODS: 69 patients who underwent short segment lumbar fusion (7 levels) between 1988 and 2001 were evaluated at a mean follow-up of 51 months (range 24–90). Our tendency was to fuse patients over age 65 short of the sacrum despite degenerative changes at L5-S1. 44 patients, mean age of 67 (median68, 64% age 65), were fused to L5 (mean levels fused2.9), and 25 patients, mean age of 58 (median56, 84%, were fused to S1 (mean levels fused excluding L5-S14.0). Radiographic measurements from preoperatively, immediately postoperatively, and a final follow-up as well as final clinical outcomes questionnaire at most recent follow-up were compared. RESULTS: The study groups were significantly different in age (p.0005) and fusion levels excluding L5-S1 (p.002) but similar in all other preoperative measurements. At follow-up, the L5 group showed pro- gression of L5-S1 degeneration, with more anterior and posterior disc height collapse (p.002, p.05) and greater loss of L5-S1 and T12-S1 lordosis (p.05, p.003). The S1 group had more scoliosis correction (p.02). There was no significant difference in L5 depth, sacral inclination, and progression of L5 olisthesis, and questionnaire scores. No patient in the L5 group went on to require subsequent fusion extension to the sacrum. CONCLUSIONS: In older patients, stopping degenerative fusions at L5 can provide similar outcomes without the added morbidity of fusing to the sacrum. Over time there is progressive loss of L5-S1 disc height and lumbar lordosis. Despite these radiographic changes, clinical outcomes remained stable and no patient required revision to the sacrum. DISCLOSURES: No disclosures. CONFLICT OF INTEREST: Author (LL) Grant Research Support: Medtronic. doi: 10.1016/j.spinee.2005.05.165 5:12 163. The radiographic failure of single segment posterior cervical instrumentation in traumatic cervical flexion distraction injuries
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Transcript of 5:06162. Preserving the degenerated L5S1 segment in degenerative lumbar fusion surgery in older...
Proceedings of the NASS 20th Annual Meeting / The Spine Journal 5 (2005) 1S–189S84S
5:36161. PLIF vs. posterolateral fusion in adult isthmic spondylolisthesisPer Ekman, MD1, Rune Hedlund, MD2, Hans Moller, MD, PhD2,Tycho Tullberg3, Pavel Neuman4; 1Karolinska Institute, Stockholm,Sweden; 2Karolinska University Hospital / Huddinge, KarolinskaInstitute, Stockholm, Huddinge, Sweden; 3Stockholm Spine Center,Stockholm, Sweden; 4Ryhovs Hospital, Jonkoping, Sweden
BACKGROUND CONTEXT: Based on a RCT we have previously re-ported an improved outcome 2 years after posterolateral fusion (PLF)compared with exercise in adult isthmic spondylolisthesis. On theorethicalgrounds PLIF has been suggested to result in an improved outcome com-pared with PLF. Data to support this view is, however, lacking.PURPOSE: To compare the outcome of PLIF with PLF in adult isthmicspondylolisthesis.STUDY DESIGN/SETTING: The outcome of prospectively identifiedadult patients with isthmic spondylolisthesis operated on with PLIF werecompared with historical controls operated on with posterolateral fusion(PLF).PATIENT SAMPLE: In this multi-center study 86 patients, age 18–55,with symptomatic adult isthmic spondylolisthesis were operated on withPLIF. The control group consisted of a historical group of 77 patientsoperated on with PLF. The two groups had similar socioeconomic, ageand sex distribution, and similar level of pain and disability.OUTCOME MEASURES: Preoperatively and at 2 years follow-up func-tional disability was quantified by the Disability Rating Index (DRI, 0–100) and pain by VAS. The Oswestry score was quantified at 2 year follow-up. Global outcome was assessed by the patient as much better, better,unchanged or worse.METHODS: The inclusion criteria and methods of outcome measurementswere identical in the PLIF and PLF-groups. The PLIF-group were operatedon with autograft and carbon fibre ramps with pedicle fixation. The PLF-group consisted of 40 patients operated with posterolateral fusion and 37patients operated on with autograft and pedicle fixation.RESULTS: The follow-up rate at present (Jan-05) is 83% (71/86 patients).Based on these patients the pain index improved from 66 preoperativelyto 36 (p�0.0001), and the DRI from 46 to 31 (p�0.01). Level of pain andDRI were similar to that of the historical PLF group (pain 37, DRI 29,ns). Similarly, the global outcome was almost identical in the two groups;71% of the patients in the PLIF-group classified the results as much betteror better compared with 75% in the PLF group (ns). The Oswestry scorewhere the same (26) in both groups at 2 year follow-up.CONCLUSIONS: Type of fusion, PLIF or PLF, is of limited importancefor the outcome of surgical treatment of adult isthmic spondylolisthesis.Despite the theorethical advantages of PLIF no improvement on patientoutcome compared with posterolateral fusion could be demonstrated, ques-tioning the need of anterior support in short lumbar fusions.DISCLOSURES: FDA device/drug: Ramps for PLIF. Status: Approvedfor this indication.CONFLICT OF INTEREST: No conflicts.
doi: 10.1016/j.spinee.2005.05.164
5:12163. The radiographic failure of single segment posterior cervicalinstrumentation in traumatic cervical flexion distraction injuries
Friday, September 30, 20055:06–5:55 PM
Concurrent Session: Degenerative
5:06162. Preserving the degenerated L5S1 segment in degenerativelumbar fusion surgery in older patients: is it possible?Stanley Lee, MD1, Lawrence Lenke, MD2, Michael Peelle, MD2,Gbolahan Okubadejo, MD3, Ivan Cheng, MD4, Robert Hurford, Jr.,MD5, Keith Bridwell, MD6, Brenda Sides, BA6, Georgia Stobbs, RN6;1University of Michigan, Ann Arbor, MI, USA; 2Washington University
in St. Louis, St. Louis, MO, USA; 3Washington University MedicalSchool, St. Louis, MO, USA; 4Stanford School of Medicine, Stanford,CA, USA; 5Carle Spine Institute, Urbana, IL, USA; 6WashingtonUniversity Medical Center, St. Louis, MO, USA
BACKGROUND CONTEXT: Spine surgeons are often faced with adilemma of whether to include a degenerated L5-S1 fusion in a lumbar fusionfor degenerative disease. Most patients with degenerative lumbar conditionspresent with some degeneration at L5-S1 that is of questionable clinicalsignificance. Fusion to S1 versus L5 presents additional perioperative riskand increased incidence of late pseudarthrosis.PURPOSE: To evaluate radiographic and clinical outcomes in degenerativelumbar spine patients fused to L5 versus S1. We hypothesize that in older,less active patients, fusion to L5 versus S1 provides similar outcomes withless morbidity.STUDY DESIGN/SETTING: A retrospective review of 69 consecutivepatients a one institution by two surgeons who underwent lumbar fusionof 7 or less levels for degenerative disease comparing outcomes of thosepatients fused to L5 versus S1. Strong consideration was given to stoppingsurgical fusion at L5 versus S1 in patients above age 65.PATIENT SAMPLE: 44 were fused to L5 and 25 were fused to S1. Therewere 19 men and 50 women with and average age of 65 at surgery (range43–77). Within the L5 group, the mean age was 67 (64%�65) and withinthe S1 group, the mean age was 56 (84%�65). The majority of the patientunderwent surgery for degenerative disease of the lumbar spine with acomponent of stenosis. Other diagnoses included adult scoliosis, post lami-nectomy syndrome, and spondylolisthesis.OUTCOME MEASURES: Preoperative, postoperative, and final follow-up radiographs were reviewed for coronal curve, L5 depth, Weiner degener-ative disc rating, T12-S1 and L5-S1 lordosis, anterior and posterior L5-S1disc height, L5-S1 olisthesis, and T12 sagittal plumb. Functional outcomewas measured by a 14 question institutional postoperative status question-naire that evaluated activity level, function, pain, cosmesis, and patient’soverall outlook.METHODS: 69 patients who underwent short segment lumbar fusion(�7 levels) between 1988 and 2001 were evaluated at a mean follow-upof 51 months (range 24–90). Our tendency was to fuse patients over age65 short of the sacrum despite degenerative changes at L5-S1. 44 patients,mean age of 67 (median�68, 64%� age 65), were fused to L5 (meanlevels fused�2.9), and 25 patients, mean age of 58 (median�56, 84%,were fused to S1 (mean levels fused excluding L5-S1�4.0). Radiographicmeasurements from preoperatively, immediately postoperatively, and a finalfollow-up as well as final clinical outcomes questionnaire at most recentfollow-up were compared.RESULTS: The study groups were significantly different in age(p�.0005) and fusion levels excluding L5-S1 (p�.002) but similar in allother preoperative measurements. At follow-up, the L5 group showed pro-gression of L5-S1 degeneration, with more anterior and posterior disc heightcollapse (p�.002, p�.05) and greater loss of L5-S1 and T12-S1 lordosis(p�.05, p�.003). The S1 group had more scoliosis correction (p�.02).There was no significant difference in L5 depth, sacral inclination, andprogression of L5 olisthesis, and questionnaire scores. No patient in theL5 group went on to require subsequent fusion extension to the sacrum.CONCLUSIONS: In older patients, stopping degenerative fusions at L5can provide similar outcomes without the added morbidity of fusing to thesacrum. Over time there is progressive loss of L5-S1 disc height and lumbarlordosis. Despite these radiographic changes, clinical outcomes remainedstable and no patient required revision to the sacrum.DISCLOSURES: No disclosures.CONFLICT OF INTEREST: Author (LL) Grant Research Support:Medtronic.
doi: 10.1016/j.spinee.2005.05.165
