Degenerative lumbar spondylolisthesis: cohort of 670 patients, and proposal of a new classification

Abstract

Degenerative spondylolisthesis is common in adults. No consensus is available about the analysis or surgical treatment of degenerative spondylolisthesis. In 2013, the French Society for Spine Surgery (Societe francaise de chirurgie du rachis) held a round table discussion to develop a classification system and assess the outcomes of the main surgical treatments. A multicentre study was conducted in nine centres located throughout France and Luxembourg. We established a database on a prospective cohort of 260 patients included between July 2011 and July 2012 and a retrospective cohort of 410 patients included in personal databases between 2009 and 2013. For patients in the prospective cohort clinical assessments were performed before and after surgery using the self-administered functional impact questionnaire AQS, SF12, and Oswestry Disability Index (ODI). Type of treatment and complications were recorded. Antero-posterior and lateral full-length radiographs were used to measure lumbar lordosis (LL), segmental lordosis (SL), pelvic incidence (PI), pelvic tilt (PT), sagittal vertical axis (SVA), and percentage of vertebral slippage. Mean follow-up was 10 months. We started a randomised clinical trial comparing posterior fusion of degenerative spondylolisthesis with versus without an inter-body cage. 60 patients were included, 30 underwent 180° fusion and 30 underwent 360° fusion using an inter-body cage implanted via a transforaminal approach. We evaluated the quality of neural decompression achieved by minimally invasive fusion technique. In a subgroup of 24 patients computed tomography (CT) was performed before and after the procedure and then compared. Mean age was 67 years and 73% of degenerative spondylolisthesis were located at L4-L5 level. The many surgical procedures performed in the prospective cohort were posterior fusion (39%), posterior fusion combined with inter-body fusion (36%), dynamic stabilization (15%), anterior lumbar fusion (8%), and postero-lateral fusion without exogenous material (2%). Peri-operative complications of any severity occurred in 17% of patients. The AQS, ODI and SF12 scores were improved significantly at follow-up. We found no differences in clinical improvements across surgical procedure types. Circumferential fusion (360°) was associated with greater relief of nerve root pain and better lordosis recovery after 1 year compared to postero-lateral fusion (180°). Post-operative CT images showed effective decompression of nervous structures after minimally invasive fusion. Longer follow-up of our patients is needed to assess the stability of the results of the various surgical procedures. Based on a radiological analysis, the authors propose a new classification with five types of degenerative spondylolisthesis: type 1, SL>5° and LL>PI-10°; type 2, SL<5° and LL>PI-10°; type 3, LL<PI-10°; type 4, LL<PI-10° and compensated sagittal balance with PT>25°; and type 5, sagittal imbalance with SVA>4 cm.

Proof level: IV Observational cohort study. Retrospective review of prospectively collected outcome data.

Keywords: Circumferential fusion; Classification; Discogenic degenerative disease; Lumbar spine osteoarthritis; Minimally invasive fusion; Sagittal balance; Spondylolisthesis.