degenerative lumbar spondylolisthesis sanjay yadla, md · pdf fileanterior subluxation of ......
TRANSCRIPT
![Page 1: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/1.jpg)
Degenerative Lumbar Degenerative Lumbar SpondylolisthesisSpondylolisthesis
Sanjay Yadla, MDSanjay Yadla, MDOctober 10, 2008October 10, 2008
Department of Neurological SurgeryDepartment of Neurological SurgeryThomas Jefferson UniversityThomas Jefferson University
![Page 2: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/2.jpg)
Lumbar SpondylolisthesisLumbar Spondylolisthesis
EpidemiologyEpidemiologyDiagnosis/ImagingDiagnosis/ImagingManagement:Management:
Conservative vs OperativeConservative vs OperativeSurgical OptionsSurgical OptionsFusion vs NonFusion vs Non--FusionFusionInstrumentation vs NonInstrumentation vs Non--InstrumentationInstrumentation
![Page 3: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/3.jpg)
Spondylolisthesis
Anterior subluxation of one vertebral body on anotherUsually L5 on S1, occasionally L4 on L5Degenerative: L4 on L5, then L4-3, and L5-S1
![Page 4: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/4.jpg)
SpondylolistheisSpondylolistheis
1950, Macnab 1950, Macnab ––spondylolisthesis with an spondylolisthesis with an intact neural archintact neural arch1955, Newman 1955, Newman ––degenerative degenerative spondylolisthesisspondylolisthesis1976, Wiltse et al 1976, Wiltse et al ––classification: congenital, classification: congenital, isthmic, degenerative, isthmic, degenerative, etc.etc.
![Page 5: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/5.jpg)
Classification
Isthmic (Spondylolysis)DysplasticTraumaticPathologicCongenital*Degenerative: due to intersegmental instability, no break in the pars
![Page 6: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/6.jpg)
Spondylolisthesis
Progressive degeneration of the facet jointsListhesis causes spinal stenosis with neurogenic claudicationPatients have been noted to have deficient coronal portions of the facet and narrow laminaPrimary symptoms are from:
Lateral recess stenosis – from forward slippage of the inferior articulating processDisk herniation – contributes to central stenosis caused by intact neural arch
![Page 7: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/7.jpg)
Spondylolisthesis: General Points
Herniated discs are rareat the level of listhesisMore often level above
Radiculopathy involves the nerve exiting under the pedicle of the subluxed vertebra
![Page 8: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/8.jpg)
Meyerding’s Scale
Grade Amount of SubluxationGrade I <25%Grade II 25-50%Grade III 50-75%Grade IV 75-100%Grade V >100% (Spondyloptosis)
Meyerding HW: Spondylolisthesis. Surg Gynecol Obstet 54:371–379, 1932.
![Page 9: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/9.jpg)
Meyerding’s Scale
![Page 10: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/10.jpg)
Spondylolysis
![Page 11: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/11.jpg)
Scottie Dog
![Page 12: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/12.jpg)
Spondylolysis
![Page 13: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/13.jpg)
Spondylolisthesis: Epidemiology
Found in :
5.8% of men9.1% of women3 times greater in African American women
Most are asymptomatic
![Page 14: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/14.jpg)
Epidemiology
Greater incidence in females:Ligamentous laxityLess lumbosacral lordosisIncreased sacralization of L5
![Page 15: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/15.jpg)
Epidemiology
![Page 16: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/16.jpg)
![Page 17: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/17.jpg)
BMI and angle of lordosis were significantly associated with disease in womenAge was significantly associated with disease in both men and womenThe male:female ratio of L4 listhesis was 1:6.4
![Page 18: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/18.jpg)
Clinical Presentation
Mechanical Back PainWorse with activityBetter with rest
Leg PainRadicularNeurogenic Claudication
Aches, fatigue, tirednessBetter with forward flexion
Bowel, Bladder Function
![Page 19: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/19.jpg)
Low back pain, and sciatica 62%Sciatica only 7%Low back pain only 31%Most common signs:
Positive SLR test, 12%L5 sensory deficit, 13%
![Page 20: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/20.jpg)
Radiographic Evaluation
Lumbosacral XraysCT Scan
“trefoil” canalMyelogram
“washboard pattern”“wasp waisting”
MRI : nerve impingement
![Page 21: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/21.jpg)
Radiologic Analysis: Anterior Displacement
A1: Superior Endplate of SacrumA/A1 = Slip PercentageGreater than 50% slip is associated with risk for progressive deformity
![Page 22: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/22.jpg)
Radiographic Analysis: Sagittal Rotation
Increased sagittal rotation is a sign of Instability and risk of progression
Severity of disease, instability, and risk of progressive deformity are greater
![Page 23: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/23.jpg)
Nonoperative Mgmt
Patients with LBP alone are treated with conservative therapy: NSAIDS, PTEpidural steroids may offer short-term reliefbut long-term prospective studies do not show a lasting effectPhysical Therapy: stretching and strengthening coupled with and aerobics program (biking, water exercise)Lumbosacral Corset/Brace
![Page 24: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/24.jpg)
Operative Mgmt: Indications
10-15% will fail conservative therapyAbsolute indications:
Progressive weaknessCauda Equina-type symptoms
Myelopathy, radiculopathy or neurogenic claudicationRadiographically documented instability
![Page 25: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/25.jpg)
Surgery vs Conservative Mgmt
![Page 26: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/26.jpg)
Surgery vs Conservative Mgmt
![Page 27: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/27.jpg)
Functional outcome (pain reduction and DRI) was better in the surgically treated group than in the exercise group at both the 1-year and 2-year follow-up assessments (p<0.01).
![Page 28: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/28.jpg)
Who Will Slip?
Patients will have 80 to 90% of their total slip at presentation44% will have a progression in their slipRisk Factors:
Greater than 20 to 30% slip at diagnosisAdolescenceMobility of motion segmentSagitally aligned facets
![Page 29: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/29.jpg)
![Page 30: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/30.jpg)
31 RCTs identifiedConflicting evidence of clinical effectiveness of fusionInstrumentation produces a higher fusion rate but improvement in clinical outcomes is probably marginal
![Page 31: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/31.jpg)
8 trials addressed whether instrumentation improves the outcome of posterolateral fusionThere is moderate evidence that instrumentation improves the fusion rateThere is conflicting evidence that instrumentation improves clinical outcomes
![Page 32: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/32.jpg)
![Page 33: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/33.jpg)
![Page 34: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/34.jpg)
Fusion: Indications
Decompression with>= Grade II SpondylolisthesisAfter repeated discectomiesUnstable (>10 degress on flex-ex films)Established mechanical back painPost-Bilateral facetectomyControversial: Decompression with Grade I, suggestive mechanical back pain, unilateral facetectomy
![Page 35: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/35.jpg)
![Page 36: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/36.jpg)
50 pts with a clinical diagnosis of degenerative spondylolisthesis and spinal stenosis who were unresponsive to an adequate course of conservative therapyRandomized to decompressive laminectomy (n=25) alone or decompressive laminectomy and bilateral intertransverse process arthrodesis (n=25)
![Page 37: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/37.jpg)
![Page 38: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/38.jpg)
Spondylolisthesis increased postoperatively in 96 versus 28 percentMarkedly improved clinical outcome was found in patient who underwent fusionAlthough the pseudoarthrosis rate was 36%, clinical results were good or excellent for all patients who underwent fusion
![Page 39: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/39.jpg)
Degenerative Lumbar Spondylolisthesis With Spinal Stenosis: A Prospective, Randomized Study
Comparing Decompressive Laminectomy and Arthrodesis With and Without Spinal
Instrumentation
Fischgrund, Jeffrey S. MD; Mackay, Michael MD; Herkowitz, Harry N. MD; Brower, Richard MD; Montgomery, David M. MD; Kurz, Lawrence T. MD
Spine. Volume 22(24), 15 December 1997, pp 2807-2812
![Page 40: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/40.jpg)
Fischgrund et al: Summary
68 patients randomized toDecompression and arthrodesisDecompression and arthrodesis and instrumentation
Instrumentation: segmental transpedicular screwsAverage follow-up of two years
![Page 41: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/41.jpg)
![Page 42: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/42.jpg)
Fischgrund et al: Rate of Fusion
![Page 43: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/43.jpg)
Fischgrund et al: Results
Clinical outcome was excellent or good in 76% of the patients in whom instrumentation was placed and in 85% of those in whom no instrumentation was placed (P = 0.45) Successful arthrodesis occurred in 82% of the instrumented cases versus 45% of the noninstrumented cases (P = 0.0015) In patients undergoing single-level posterolateral fusion for degenerative spondylolisthesis with spinal stenosis, the use of pedicle screws may lead to a higher fusion rate, but clinical outcome shows no improvement in pain in the back and lower limbs
![Page 44: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/44.jpg)
![Page 45: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/45.jpg)
47 patients prospectively studiedUnderwent Posterior decompression and bilateral posterolateral arthrodesis with autogenous bone graft.Follow up from 5 to 14 years: fusion or pseudoarthrosis, clinical analysis
![Page 46: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/46.jpg)
Preoperative back and lower limb pain scores were similar between the two groupsClinical outcome was excellent to good in 86% of patients with a solid arthrodesis and 56% in patients with a pseudoarthrosis (p=0.01)
![Page 47: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/47.jpg)
The Effect of Pedicle Screw Instrumentation on Functional Outcome and Fusion Rates in
Posterolateral Lumbar Spinal Fusion: A Prospective,Randomized Clinical Study
Thomsen, Karsten MD, DMSc; Christensen, Finn B. MD; Eiskjær, Søren P. MD; Hansen, Ebbe S. MD; Fruensgaard, Søren MD†; Bünger, Cody E. MD
Spine. Volume 22(24), 15 December 1997, pp 2813-2822
![Page 48: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/48.jpg)
Karsten et al: Outcomes
Significantly better (P < 0.05) functional outcome in relation to daily activities in the instrumented group when neural decompression had been performed. Global patients' satisfaction was 82% in the instrumented group versus 74% in the non-instrumented group (not significant). Significant symptoms from misplacement of pedicle screws were seen in 4.8% of the instrumented patients.
![Page 49: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/49.jpg)
Karsten et al: Conclusions
Lumbar posterolateral fusion with pedicle screw fixation increases the operation time, blood loss, and reoperation rate, and leads to a significant risk of nerve injury. A gain in functional outcome was found in the daily activity category in patients with instrumentation and supplementary neural decompression. The results of this study do not justify the general use of pedicle screw fixation alone as an adjunct to posterolateral lumbar fusion.
![Page 50: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/50.jpg)
TLIF: Technique
![Page 51: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/51.jpg)
![Page 52: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/52.jpg)
TLIF: Technique
![Page 53: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/53.jpg)
TLIF: Technique
![Page 54: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/54.jpg)
Surgical Treatments
Pathology: Nerve root compression within confines of spinal canal
Type of Procedure: Decompression with preservation of facets
![Page 55: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/55.jpg)
Surgical Treatments
Pathology: Spinal stenosis at the level of spondylolisthesis
Type of Procedure: Decompression*some advocate intertransverse process fusion
![Page 56: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/56.jpg)
Surgical Treatments
Pathology: Nerve root compression far lateral, outside confines of spinal canal
Type of Procedure: Radical decompression plus fusion (i.e. Gill procedure)
![Page 57: Degenerative Lumbar Spondylolisthesis Sanjay Yadla, MD · PDF fileAnterior subluxation of ... from forward slippage of the inferior articulating process ... Underwent Posterior decompression](https://reader030.vdocuments.site/reader030/viewer/2022021509/5aa06cb37f8b9a8e178df68f/html5/thumbnails/57.jpg)
What’s Next: Dynamic Stabilization
Outcome after fusion appears to be quite inconsistent