Original Article
Clinical Outcome of Percutaneous Fixation in Symptomatic Lumbosacral Spondylolisthesis Mahmoud I. Abdel-Ghany1, Mohammed A. Yehia1, Ahmed I. Abdel-Salam1, Abdel-Hamid Abdel-Aziz1, Mohammed Al-Wardany2 Departments of Orthopedics1, Al-Azhar University; Neurosurgery2, Ain Shams University; Egypt
ABSTRACT Background: Minimally invasive techniques in spinal surgery are increasing popularity as it reducing length of stay, morbidity risk, post-operative analgesia and early return to work. Objective: A prospective study to evaluate the clinical outcome of percutaneous fixation for disabling low back pain associated with lumbosacral GI spondylolisthesis. Methods: Twenty patients with 1st degree lumbar spondylolisthesis underwent percutaneous fixation after failure of at least 6 months of conservative treatment. All patients with neurological compromise and requiring decompression or had previous spine surgery were excluded. There were 16 males (80%) and four female (20%). Patient’s age ranged from 30 to 42 years old with average age 37 years old. Clinical outcome was evaluated by Japanese Orthopedic Association Score (JAOS). Operative time, blood loss, and postoperative pain were also recorded. Results: Average follow up periods were 15.5 months. According to JOAS mean preoperative score was 18, which are improved to mean 27.85. Overall results were excellent mean improvement rate were 89.76%. Mean operative time 96 minutes; mean blood loss was 100 mL. Postoperative X-Ray has proper screws position. The complications occurred in two cases (10%) and dealt with them accordingly. Conclusion: Percutaneous fixation for management of symptomatic 1st lumbosacral spondylolisthesis allows for safe and efficient minimally invasive procedure had good clinical results. Further prospective studies with long-term follow-up results are required to assess the definitive merits of percutaneous instrumentation of the lumbar spine. [Egypt J Neurol Psychiat Neurosurg. 2014; 51(3): 287-293] Key Words: Percutaneous, Spondylolisthesis, Minimally invasive surgery.
INTRODUCTION Pedicle screws have superior biomechanical as well as clinical data when compared to other methods of instrumentation1,2. Several authors have been reported that the open posterior approach and instrumentation for the lumbosacral spine possibly adds relevant damage to the dorsal musculature and as a consequence continuous impairments can remains.3-5 Irrespective of the exact method of arthrodesis, conventionally open lumbar surgery performed via a posterior approach is associated with significant soft tissue morbidity that can adversely affect patient outcomes.6,7 Currently, there has been increased awareness of the need to preserve stability and minimize destruction to tissues not directly involved in the pathological process. Several authors have described their experiences with minimally invasive surgery for different pathology and reported its efficacy and safety. However, these techniques are technically demanding even though their results have been reported to be favorable.8-10 Correspondence to Mahmoud I. Abdel-Ghany, Orthopedics Department, Al-Azhar University, Egypt Tel.: +201005196727 Email:
[email protected]
Egypt J Neurol Psychiat Neurosurg. │July 2014 │ Vol 51 │ Issue 3
Aim of work: To evaluate an alternative minimal invasive technique for the treatment of 1st degree lumbosacral spondylolisthesis regarding the technique and to determine its clinical outcome.
PATIENTS AND METHODS From March 2009 to May 2010 twenty patients diagnosed to have 1st degree spondylolisthesis of the lumbosacral spine resulting in axial back pain and claudication, without other radicular symptoms underwent percutaneous pedicle screw fixation (PPSF) after failure of at least 6 months of conservative treatment. Patients who proved had neurological deficits and requiring decompression or had previous spine surgery were excluded from the study. There were 16 males (80%) and four females (20%). Patients’ ages ranged from 30 to 42 years old with average 37 years old. The clinical status of all patients had been evaluated and so the clinical outcome was assessed by JOAS.11 JOAS were recorded for all patients before surgery and after surgery regularly to the last follow up visit. Calculation of Improvement rate by using the 287
Abdel-Ghany, et al.: Percutaneous Fixation in Lumbosacral Spondylolisthesis
formula included in the score by calculating the total score before surgery and the last follow up score. Radiological evaluation by plain X-ray AP, lateral and oblique films (right and left oblique) on the lumbosacral spine region and dynamic views (lateral standing flexion-extension) to evaluate the stability of the affected segment. Magnetic Resonance Imaging (MRI) of the lumbosacral spine was also performed for all patients to confirm that there is no need for decompression of the neural elements. Intra-operative blood loss, time of surgery, intra-operative blood loss, and were recorded. The main complaint of patients was low back pain with an average duration of complaint 1.8 years. The duration of complaint was less than 3 years in 13 patients (65%) and less than 5 years in 7 patients (35%). Fifteen patients (75%) had continuous severe back pain that led to reduction of their activities of daily living. Five patients (25%) had frequent mild back pain or occasional severe pain that also that led to reduction of their daily living activities. Six patients (30%) had low back pain associated with unilateral leg pain. The level of fusion for all patients were L5-S1 and grade of slipping is G1 on Myerding’s Scale with few mm. displacement which usually does not appears until dynamic films were obtained. All patient in this study treated surgically by minimal invasive procedure using percutaneous pedicle screws fixation with Sextant rod system (Medtronic SofamorDanek, USA®) in all cases. After induction of general anesthesia, patients were positioned prone on a radiolucent frame. Fluoroscopic image was used directly after positioning to identify and draw crossed lines over the skin at the pedicle site before scrubbing (Figure 1). Bone marrow (BM) injection needle with sharp trocar (Islam Needle Manufactured by Down®) were used initially to access the pedicle with fluoroscopic confirmation (AP and lateral view) (Figure 2). Guide wire inserted through the BM needle in the center of the pedicle and the needle is removed and fluoroscopic control. Cannulated screws with poly-axial screw heads that connect to extension sleeves were inserted. Precontoured suitable length rod were inserted and interconnected to the pedicle screw heads through special Assembly of the system (Figure 3). The accuracy of pedicle screw position was evaluated by direct postoperative plain X-ray AP and Lateral views (Figure 4). The average operative time was 96 minutes (ranged 60-140 minutes). The average estimated blood loss was 100mL (ranged 75-150 mL). Postoperatively
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all patients were advised to use lumbosacral support orthosis when out of bed for 12 weeks. In all patients, sitting and walking were allowed at the same day of surgery. All patients were discharged from hospital at 2-6 days postoperatively. The mean postoperative stay was 3 days. For manual worker patients light work was allowed after 8 weeks while active work was allowed after 3 months. For heavy strain worker patients work activities modification was advised where returning to their high normal level work activity was not allowed for at least 6 months after surgery.
Statistical Analysis Statistical analysis of the results including mean values and standard deviations was performed using SPSS version16, to analyze all clinical data pre and postoperatively according to JOAS. We also used ChiSquare test and Simple T-test to compare pre and postoperative data. Differences were considered statistically significant at p
