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Surgical Options for Lumbar Spondylolisthesis: Maximizing Hardware Savings

This article discusses surgical options for treating lumbar spondylolisthesis, including laminectomy alone, laminectomy with fusion, and instrumented fusion. It also explores the role of facet cysts, facet joint angles, and patient selection in determining the appropriate surgical approach.

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Surgical Options for Lumbar Spondylolisthesis: Maximizing Hardware Savings

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  1. 55yo Manual Laborer with L4-5 Degen Spondy: Save My Hardware Dollars Please!!!! Scott D. Boden, MD Professor and Chair, Department of Orthopaedics Emory University School of Medicine Atlanta, Georgia

  2. Guiding Concepts

  3. KEY QUESTIONS • Leg Pain +/- LBP • Gross Instability Y/N? • Facet Cyst Y/N? • Sagittal/Coronal Facet Joint Angles? • High/Low Demand – Age?

  4. Patient Selection X

  5. SURGICAL OPTIONS • Laminectomy Alone • Laminectomy + In Situ Fusion • Laminectomy + Instrumented Fusion • Lami + 360o fusion • ? Limited Instrumentation

  6. Nancy E. Epstein, MD • 90-95% of DS may be treated with decompression WITHOUT fusion • Fuse when: • Clinical Evidence of Instability • Post-Op Slip Progression

  7. Harry Herkowitz/ Jeff Fischgrund • 1997 Volvo Award Paper • Prospective, Randomized 76 pts • Lami/Fusion In Situ vs Instrumented • Instrumentation: • Increased Fusion Success Rate • Clinical success NOT correlated with fusion success

  8. Lami + Instrumented Fusion vs Lami Alone The New England Journal of Medicine Laminectomy plus Fusion versus Laminectomy Alone for Lumbar Spondylolisthesis Zoher Ghogawala, M.D., James Dziura, Ph.D., William E. Butler, M.D., Feng Dai, Ph.D., Norma Terrin, Ph.D., Subu N. Magge, M.D., Jean-Valery C.E. Coumans, M.D., J. Fred Harrington, M.D., Sepideh Amin-Hanjani, M.D., J. Sanford Schwartz, M.D., Volker K.H. Sonntag, M.D., Fred G. Barker, II, M.D., and Edward C. Benzel, M.D. • April 2016 • Only 66 patients randomized • 86% f/u at 2 yrs, 68% f/u at 4 yrs • Grade I Degen Spondy Conclusions • Fusion had slightly better clinical outcomes compared to lami alone

  9. August 2018 • Only 85 patients randomized • 86% f/u at 5 yrs • Grade I Degen Spondy Conclusions • No Difference between any of the groups at 1 and 5 years

  10. The mean orientation of the lumbar facet angles relative to the coronal plane was more sagittal at all levels in the patients who had degenerative spondylolisthesis. The greatest difference was at the level of the fourth and fifth lumbar vertebrae (p = 0.000001). The mean facet angle was 41 degrees (95 per cent confidence interval, 37.6 to 44.6 degrees) in the asymptomatic volunteers and 60 degrees (95 per cent confidence interval, 52.7 to 67.1 degrees) in the patients who had degenerative spondylolisthesis. Furthermore, both the left and the right facet joints were more sagittally oriented in the patients who had degenerative spondylolisthesis. An individual in whom both facet joint angles at the level of the fourth and fifth lumbar vertebrae were more than 45 degrees relative to the coronal plane was twenty-five times more likely to have degenerative spondylolisthesis (95 per cent confidence interval, seven to ninety-eight times). The increase in facet angles at levels other than that of the spondylolisthesis suggests that increased facet angles represent variations in anatomy rather than a secondary result of spondylolisthesis.

  11. Radiographic Fusion Rate 11/11 p=.02 9/9 p=.03 2/5

  12. DegenSpondy: Surgical Options

  13. THANK YOU!

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