Triple-level degenerative spondylolisthesis and the importance of spinopelvic parameters: Case report

Abstract The relation of the pelvis to the spine has previously been overlooked as a contributor to sagittal balance. However, it is now recognized that spinopelvic alignment is important to maintain an energy-efficient posture in normal and disease states. The pelvis is characterized by an important anatomic landmark, the pelvic incidence (PI). The PI does not change after adolescence, and it directly influences pelvic alignment, including the parameters of pelvic tilt (PT) and sacral slope (SS) (PI = PT 1 SS), overall sagittal spinal balance, and lumbar lordosis. In the setting of an elevated PI, the spineadapts with increased lumbar lordosis. To prevent or limit sagittal imbalance, the spine may also compensate with increased PT or pelvic retroversion to attempt to maintain anupright posture. Abnormal spinopelvic parameters contribute to multiple spinal conditions including isthmic spondylolysis, degenerative spondylolisthesis, deformity, and impact outcome after spinal fusion. Sagittal balance, pelvic incidence, and all spinopelvic parameters are easily and reliably measured on standing, full-spine (lateral) radiographs, and it is essential to accurately assess and measure these sagittal values to understand their potential role in the disease process, and to promote spinopelvic balance at surgery. In this article, we provide a comprehensive review of the literature regarding the implications of abnormal spinopelvic parameters and discuss surgical strategies for correction of sagittal balance. Additionally, the authors rate and critique the quality of the literature cited in a systematic review approach to give the reader an estimate of the veracity of the conclusions reached from these reports.

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Implications of Spinopelvic Alignment for the Spine Surgeon

Neurosurgery ◽

10.1227/01.neu.0000462077.50830.1a ◽

2011 ◽

Vol 76 (suppl_1) ◽

pp. S42-S56 ◽

Cited By ~ 29

Author(s):

Vivek A. Mehta ◽

Anubhav Amin ◽

Ibrahim Omeis ◽

Ziya L. Gokaslan ◽

Oren N. Gottfried

Keyword(s):

Sagittal Balance ◽

Lumbar Lordosis ◽

Pelvic Incidence ◽

Degenerative Spondylolisthesis ◽

Disease Process ◽

Sacral Slope ◽

Sagittal Imbalance ◽

Spinopelvic Parameters ◽

Spinopelvic Alignment ◽

Spinopelvic Balance

Abstract The relation of the pelvis to the spine has previously been overlooked as a contributor to sagittal balance. However, it is now recognized that spinopelvic alignment is important to maintain an energy-efficient posture in normal and disease states. The pelvis is characterized by an important anatomic landmark, the pelvic incidence (PI). The PI does not change after adolescence, and it directly influences pelvic alignment, including the parameters of pelvic tilt (PT) and sacral slope (SS) (PI = PT 1 SS), overall sagittal spinal balance, and lumbar lordosis. In the setting of an elevated PI, the spineadapts with increased lumbar lordosis. To prevent or limit sagittal imbalance, the spine may also compensate with increased PT or pelvic retroversion to attempt to maintain anupright posture. Abnormal spinopelvic parameters contribute to multiple spinal conditions including isthmic spondylolysis, degenerative spondylolisthesis, deformity, and impact outcome after spinal fusion. Sagittal balance, pelvic incidence, and all spinopelvic parameters are easily and reliably measured on standing, full-spine (lateral) radiographs, and it is essential to accurately assess and measure these sagittal values to understand their potential role in the disease process, and to promote spinopelvic balance at surgery. In this article, we provide a comprehensive review of the literature regarding the implications of abnormal spinopelvic parameters and discuss surgical strategies for correction of sagittal balance. Additionally, the authors rate and critique the quality of the literature cited in a systematic review approach to give the reader an estimate of the veracity of the conclusions reached from these reports.

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Analysis of Spinopelvic Sagittal Balance and Persistent Low Back Pain (PLBP) for Degenerative Spondylolisthesis (DS) following Posterior Lumbar Interbody Fusion (PLIF)

Pain Research and Management ◽

10.1155/2020/5971937 ◽

2020 ◽

Vol 2020 ◽

pp. 1-7

Author(s):

Shuangjun He ◽

Yijian Zhang ◽

Wei Ji ◽

Hao Liu ◽

Fan He ◽

...

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Clinical Outcomes ◽

Sagittal Balance ◽

Interbody Fusion ◽

Degenerative Spondylolisthesis ◽

Posterior Lumbar Interbody Fusion ◽

Low Back ◽

Lumbar Interbody Fusion ◽

Spinopelvic Parameters

Objective. To investigate the change of spinopelvic sagittal balance and clinical outcomes after posterior lumbar interbody fusion (PLIF) in patients with degenerative spondylolisthesis (DS), especially the relationship between sagittal spinopelvic parameters and persistent low back pain (PLBP). Methods. 107 patients who were diagnosed with DS and underwent PLIF in our department were enrolled retrospectively in the present study. Sagittal spinopelvic parameters including lumbar lordosis (LL), segmental lordosis (SL), height of the disc (HOD), sacral slope (SS), pelvic incidence (PI), and pelvic tilt (PT) were recorded pre- and postoperatively. Sagittal balance and clinical outcomes were compared between patients with and without PLBP. Pearson correlation was used to analyze the change of sagittal balance parameters and clinical functions. Logistic regression analysis was performed to examine the risk factors of PLBP. Results. It showed significant improvements of SL, HOD, and PT postoperatively. Both the Numeric Rating Scale (NRS) and Oswestry Disability Index (ODI) had significant improvement postoperatively. Change of PT and SL also differed observably between patients with and without PLBP. SL and PT were correlated with NRS and ODI, and insufficient restoration of PT was an independent factor for PLBP. Conclusion. The sagittal balance parameters and clinical outcomes can be improved markedly via PLIF for treating DS. Restoration of SL and PT was correlated with satisfactory outcomes, and adequate improvement of PT may have positive impact on reducing PLBP.

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Spinopelvic Sagittal Alignment after Microendoscopic Laminotomy in Patients with Lumbar Degenerative Spondylolisthesis

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0038-1666847 ◽

2018 ◽

Vol 79 (06) ◽

pp. 479-485

Author(s):

Sho Dohzono ◽

Yusuke Hori ◽

Shinji Takahashi ◽

Akinobu Suzuki ◽

Hidetomi Terai ◽

...

Keyword(s):

Sagittal Alignment ◽

Degenerative Spondylolisthesis ◽

Group Versus ◽

Leg Pain ◽

Sacral Slope ◽

Sagittal Imbalance ◽

Low Grade ◽

Spinopelvic Parameters ◽

Spinal Sagittal Alignment ◽

Global Sagittal Alignment

Background and Study Aims Spinopelvic sagittal balance is important in managing lumbar diseases. We evaluated the change in spinal sagittal alignment after microendoscopic laminotomy in patients with low-grade degenerative spondylolisthesis (DS). Material and Methods We retrospectively reviewed the records of 87 patients who underwent microendoscopic laminotomy. We enrolled 35 patients with DS and 52 patients without DS. Spinopelvic parameters were evaluated, including the sagittal vertical axis (SVA), lumbar lordosis (LL), sacral slope, pelvic tilt, and pelvic incidence (PI). Primary outcome was a change in spinopelvic alignment between the baseline and latest follow-up values (DS group versus non-DS group). Secondary outcomes were the relationships between improved global sagittal alignment and preoperative spinopelvic parameters. Results Both groups showed significantly alleviated low back pain (LBP), leg pain, and leg numbness. Preoperative SVA and PI were significantly higher in the DS group than in the non-DS group (p < 0.05). SVA significantly decreased and LL significantly increased in the DS group (p < 0.05), whereas those parameters did not differ significantly from before versus after surgery in the non-DS group. In both groups, SVA improvement correlated significantly with preoperative SVA (DS: r = 0.702; non-DS: r = 0.397). There was also a significant intergroup difference in the correlation coefficient (z = 1.98; r = 0.048). Conclusions SVA and LL significantly improved after microscopic laminotomy in patients with low-grade DS and neurologic symptoms. SVA improvement in the DS group was correlated with preoperative spinopelvic sagittal imbalance. The strength of those correlations was greater in the DS group than in the non-DS group.

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Degenerative Spondylolisthesis at the L4–L5 in a 32-Year-Old Female with Previous Fusion for Idiopathic Scoliosis: A Case Report

Journal of Orthopaedic Surgery ◽

10.1177/230949900301100217 ◽

2003 ◽

Vol 11 (2) ◽

pp. 202-206 ◽

Cited By ~ 5

Author(s):

RB Winter ◽

BJ Silverman

Keyword(s):

Case Report ◽

Idiopathic Scoliosis ◽

Degenerative Spondylolisthesis

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Long Term Observation of Degenerative Spondylolisthesis. A Case Report.

Orthopedics & Traumatology ◽

10.5035/nishiseisai.42.1126 ◽

1993 ◽

Vol 42 (3) ◽

pp. 1126-1130

Author(s):

Masatoshi Yamada ◽

Yasushi Asakawa ◽

Kousuke Ogata ◽

Jun Arimizu ◽

Toyonobu Yoshimura

Keyword(s):

Case Report ◽

Degenerative Spondylolisthesis ◽

Long Term Observation

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Sagittal spinopelvic parameters in 2-level lumbar degenerative spondylolisthesis

Medicine ◽

10.1097/md.0000000000005417 ◽

2016 ◽

Vol 95 (50) ◽

pp. e5417 ◽

Cited By ~ 6

Author(s):

Tao Wang ◽

Hui Wang ◽

Huan Liu ◽

Lei Ma ◽

Feng-Yu Liu ◽

...

Keyword(s):

Degenerative Spondylolisthesis ◽

Spinopelvic Parameters ◽

Lumbar Degenerative Spondylolisthesis

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The influence of spinopelvic parameters on adjacent-segment degeneration after short spinal fusion for degenerative spondylolisthesis

Journal of Neurosurgery Spine ◽

10.3171/2018.2.spine171160 ◽

2018 ◽

Vol 29 (4) ◽

pp. 407-413 ◽

Cited By ~ 4

Author(s):

Ming-Kai Hsieh ◽

Fu-Cheng Kao ◽

Wen-Jer Chen ◽

I-Jung Chen ◽

Sheng-Fen Wang

Keyword(s):

Spinal Fusion ◽

Degenerative Spondylolisthesis ◽

Slope Angle ◽

Adjacent Segment Degeneration ◽

Control Group ◽

Adjacent Segment ◽

Spinopelvic Parameters ◽

Lumbosacral Fusion ◽

Single Level ◽

Matching Criteria

OBJECTIVESpinopelvic parameters, such as the pelvic incidence (PI) angle, sacral slope angle, and pelvic tilt angle, are important anatomical indices for determining the sagittal curvature of the spine and the individual variability of the lumbar lordosis (LL) curve. The aim of this study was to investigate the influence of spinopelvic parameters and LL on adjacent-segment degeneration (ASD) after short lumbar and lumbosacral fusion for single-level degenerative spondylolisthesis.METHODSThe authors retrospectively reviewed the records of all short lumbar and lumbosacral fusion surgeries performed between August 2003 and July 2010 for single-level degenerative spondylolisthesis in their orthopedic department.RESULTSA total of 30 patients (21 women and 9 men, mean age 64 years) with ASD after lower lumbar or lumbosacral fusion surgery comprised the study group. Thirty matched patients (21 women and 9 men, mean age 63 years) without ASD comprised the control group, according to the following matching criteria: same diagnosis on admission, similar pathologic level (≤ 1 level difference), similar sex, and age. The average follow-up was 6.8 years (range 5–8 years). The spinopelvic parameters had no significant influence on ASD after short spinal fusion.CONCLUSIONSNeither the spinopelvic parameters nor a mismatch of PI and LL were significant factors responsible for ASD after short spinal fusion due to single-level degenerative spondylolisthesis.

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Trans-foraminal endoscopic uniportal decompression in degenerative lumbar spondylolisthesis: a technical and case report

Egyptian Journal of Neurosurgery ◽

10.1186/s41984-019-0065-4 ◽

2019 ◽

Vol 34 (1) ◽

Author(s):

Ajay Krishnan ◽

Mahesh Kulkarni ◽

Mreetaunjay Singh ◽

Chaitanya Reddy ◽

Shivanand Mayi ◽

...

Keyword(s):

Case Report ◽

Spinal Fusion ◽

Lumbar Disc ◽

Degenerative Spondylolisthesis ◽

Lateral Recess ◽

Excellent Outcome ◽

Lateral Recess Stenosis ◽

Select Group ◽

Degenerative Lumbar Spondylolisthesis ◽

Endoscopic Lumbar Discectomy

Abstract Background Degenerative spondylolisthesis is a common spinal pathology. Traditionally, spinal fusion is an accepted standard surgical treatment for listhesis. But fusion is a major intervention with its known pitfalls. With technological progression, minimally invasive spinal fusion (MISF) procedures are becoming mainstream. Percutaneous trans-foraminal endoscopic lumbar discectomy/decompressions (PTELD) without stabilization has many advantages over even a MISF for select group of patients. Case presentation In this case report, we describe using a uniportal unilateral trans-foraminal approach (TFA) for stable listhesis with lumbar disc herniation (LDH) causing chronic bilateral radicular symptoms and back pain with acute exacerbation. Under local anesthesia, we used a flat entry for PTELD, which facilitates an approach to both disc sides ventrally and even dorsal aspect lateral recess decompression on the dominant ipsilateral side. No fixation was done. An excellent outcome is obtained immediately at 6 weeks and maintained at 39 months of follow-up. Conclusion PTELD is worth considering as an intermediate procedure before fusion is offered in lateral recess stenosis in stable listhesis patients who have consented and understand the progressive cascade of spinal degeneration.

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Influence of postoperative sagittal balance and spinopelvic parameters on the outcome of patients surgically treated for degenerative lumbar spondylolisthesis

Journal of Neurosurgery Spine ◽

10.3171/2016.9.spine1680 ◽

2017 ◽

Vol 26 (4) ◽

pp. 448-453 ◽

Cited By ~ 17

Author(s):

Ingrid Radovanovic ◽

Jennifer C. Urquhart ◽

Venkat Ganapathy ◽

Fawaz Siddiqi ◽

Kevin R. Gurr ◽

...

Keyword(s):

Outcome Measures ◽

Sagittal Balance ◽

Sagittal Alignment ◽

Degenerative Spondylolisthesis ◽

Consecutive Series ◽

Spinopelvic Parameters ◽

Degenerative Lumbar Spondylolisthesis ◽

Global Sagittal Alignment ◽

Lumbar Degenerative Spondylolisthesis ◽

Multiple Levels

OBJECTIVE The object of this study was to determine the association between postoperative sagittal spinopelvic alignment and patient-rated outcome measures following decompression and fusion for lumbar degenerative spondylolisthesis. METHODS The authors identified a consecutive series of patients who had undergone surgery for lumbar degenerative spondylolisthesis between 2008 and 2012, with an average follow-up of 3 years (range 1–6 years). Surgery was performed to address the clinical symptoms of spinal stenosis, not global sagittal alignment. Sagittal alignment was only assessed postoperatively. Patients were divided into 2 groups based on a postoperative sagittal vertical axis (SVA) < 50 mm (well aligned) or ≥ 50 mm (poorly aligned). Baseline demographic, procedure, and outcome measures were compared between the groups. Postoperative outcome measures and postoperative spinopelvic parameters were compared between groups using analysis of covariance. RESULTS Of the 84 patients included in this study, 46.4% had an SVA < 50 mm. Multiple levels of spondylolisthesis (p = 0.044), spondylolisthesis at the L3–4 level (p = 0.046), and multiple levels treated with fusion (p = 0.028) were more common among patients in the group with an SVA ≥ 50 mm. Patients with an SVA ≥ 50 mm had a worse SF-36 physical component summary (PCS) score (p = 0.018), a worse Oswestry Disability Index (ODI; p = 0.043), and more back pain (p = 0.039) than those with an SVA < 50 mm after controlling for multiple levels of spondylolisthesis and multilevel fusion. The spinopelvic parameters differing between the < 50-mm and ≥ 50-mm groups included lumbar lordosis (LL; 56.4° ± 4.7° vs 49.8° ± 4.3°, respectively, p = 0.040) and LL < pelvic incidence ± 9° (51% vs 23.1%, respectively, p = 0.013) after controlling for type of surgical procedure. CONCLUSIONS Data in this study revealed that patient-rated outcome is influenced by the overall postoperative sagittal balance as defined by the SVA.

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