Evaluating Instability in Degenerative Lumbar Spondylolisthesis

Abstract

Background: The subjective degenerative spondylolisthesis instability classification (S-DSIC) system attempts to define preoperative instability associated with degenerative lumbar spondylolisthesis (DLS). The system guides surgical decision-making based on numerous indicators of instability that surgeons subjectively assess and incorporate. A more objective classification is warranted in order to decrease variation among surgeons. In this study, our objectives included (1) proposing an objective version of the DSIC system (O-DSIC) based on the best available clinical and biomechanical data and (2) comparing subjective surgeon perceptions (S-DSIC) with an objective measure (O-DSIC) of instability related to DLS. Methods:In this multicenter cohort study, we prospectively enrolled 408 consecutive adult patients who received surgery for symptomatic DLS. Surgeons prospectively categorized preoperative instability using the existing S-DSIC system. Subsequently, an O-DSIC system was created. Variables selected for inclusion were assigned point values based on previously determined evidence quality. DSIC types were derived by point summation: 0 to 2 points was considered stable, Type I); 3 points, potentially unstable, Type II; and 4 to 5 points, unstable, Type III. Surgeons' subjective perceptions of instability (S-DSIC) were retrospectively compared with O-DSIC types. Results:The O-DSIC system includes 5 variables: presence of facet effusion, disc height preservation ( ‡6.5 mm), translation ( ‡4 mm), a kyphotic or neutral disc angle in flexion, and low back pain ( ‡5 of 10 intensity). Type I (n = 176, 57.0%) and Type II (n = 164, 53.0%) were the most common DSIC types according to the O-DSIC and S-DSIC systems, respectively. Surgeons categorized higher degrees of instability with the S-DSIC than the O-DSIC system in 130 patients (42%) (p < 0.001). The assignment of DSIC types was not influenced by demographic variables with either system. Conclusions:The O-DSIC system facilitates objective assessment of preoperative instability related to DLS. Surgeons assigned higher degrees of instability with the S-DSIC than the O-DSIC system in 42% of cases.Level of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence. Degenerative lumbar spondylolisthesis (DLS) is an acquired anterior translation of 2 adjacent vertebrae 1 . Patients with DLS may develop radiculopathy or neurogenic claudication, with or without low back pain (LBP). Current evidence supports the role of surgery, primarily for the decompression of neural elements 2 . Instability is a common indication for surgical stabilization 3 . Decompression and fusion have been suggested to improve clinical outcomes for symptomatic DLS when compared with decompression alone. Three recent randomized controlled trials found no major advantage for either laminectomy alone or laminectomy plus fusion in patients with spinal stenosis; however, none of the studies captured patients with traditional horizontal translational instab...

Preliminary Results of The Treatment for Failed Back Surgery Syndrome by Full Endoscopic Approach at Saint Paul General Hospital, in Hanoi, Vietnam

“…When the patient shows no or very little back pain, accompanied by signs of disc height loss, many bony spurs around the disc or joint detected on CT, are signs of the stable condition of the adjacent disc level. However, determining the stability of the degenerative spine in adults is still controversial, with no genuinely accurate and precise standards yet [13]. Therefore, more future research is needed on the issue of determining the stability and instability of the spine based on clinical and imaging criteria to select appropriate patients to carry out immediate spinal stabilization instead of simple endoscopic decompression-potential risk of instability later [6].…”